HLTH 4913 Module 5 Final Capstone Paper and Employment Portfolio Example

Getting Heart Failure Patients Seen in the First Week: The Final Capstone Paper and an Employment Portfolio Built From It

Student Name

American College of Education

HLTH4913: Senior Capstone Experience: Healthcare Administration

Module 5 Assignment

Instructor Name

November 2, 2026

Executive Summary

Fewer than half, 41%, of the roughly 760 patients sent home each year from a composite 240-bed community hospital after a heart failure admission saw a clinician within a week, and 23.8% returned to the hospital within 30 days. This capstone examined why and what the hospital should do. The baseline data showed that whether a patient left with an appointment booked mattered more than any other factor: 55% of patients with a booked appointment were seen within the week, compared with 21% of those without one. Patients who missed follow-up most often cited transportation and not knowing about the appointment.

The capstone recommends a four-part bundle: make sure no patient leaves without a booked visit shown at the top of the discharge papers; add a half-time transportation navigator who activates existing Medicaid and Medicare Advantage ride benefits and funds rides for patients without them; arrange a nurse home visit in the first three days for the one patient in four at greatest risk; and switch the visit to video for anyone who cannot make the trip. First-year cost is about $78,300, against an estimated $284,000 in avoided readmission costs if the readmission target is met. The plan pilots on one unit before spreading and measures delivery as well as results.

The Problem and Its Evidence

The problem matters to patients, to the hospital and to the community. For patients, the first week after a heart failure admission is a period of changed medicines and shifting fluid status, and national registry data link hospitals that provide more early follow-up with lower readmission rates, although the relationship is observational (Hernandez et al., 2010). For the hospital, a federal program trims Medicare payments by as much as 3% when readmissions for heart failure and several other conditions run above expected levels (Centers for Medicare & Medicaid Services, 2026), and each readmission occupies a bed during the busiest months. For the community, older residents without cars face a bus system that stops early and skips several townships, while ride benefits that some already hold go unused.

What the Evidence and Analysis Found

The literature review produced a result that redirected the project. Pooled randomized trials showed that three kinds of service, nurses visiting at home, nurses managing cases and clinics dedicated to the disease, each cut readmissions after a heart failure stay, and home visits by nurses also saved the most money of any service studied (Van Spall et al., 2017). A trial that simply offered free rides to Medicaid patients, by contrast, saw few takers and the same share of missed visits as before. The capstone therefore stopped treating transportation as a stand-alone fix and began treating it as one part of a reliable transition process.

The analysis confirmed that view. A cause-and-effect diagram and a Pareto ranking showed transportation and unknown appointments accounting for most missed visits. Stratifying by payer showed that dual-eligible patients had an unused Medicaid ride benefit and that patients living more than 15 miles away missed visits at nearly twice the rate of others. A weighted decision matrix comparing five options favored a bundle over any single option.

The Recommendation and Plan

The recommendation is the four-part bundle, sponsored by the chief nursing officer and managed by the director of case management. Implementation runs in three phases: two months to build the discharge rule, hire the navigator and secure home health and clinic capacity; a two-month pilot on one medical unit with weekly review of every missed appointment; and spread to the second unit and the observation unit. The goals for the first year are 65% of patients seen within seven days and readmissions at or below 20%.

The evaluation asks two separate questions: did staff actually deliver the bundle, and did it change results? Delivery is tracked through how often patients go home with the appointment printed up front, the share asked about transport, the share of high-risk patients visited by day three, and cost against budget. Outcome measures are seven-day follow-up, 30-day readmission and 30-day emergency visits, with discharge delay as a balancing measure, all shown on monthly run charts against a year of baseline and stratified by payer and distance. Formal decisions follow the pilot and at months nine and twelve. The bundle is ordinary on purpose: each part uses a role the hospital already understands, joined so that no patient falls between them.

Limitations

The capstone has limits that administration should weigh. Its data come from one hospital and one year, and the difference in readmissions between patients who were and were not seen within a week is not adjusted for how ill they were. The survey heard only from patients who picked up the phone, and the ones it missed may have had different reasons. Transitional care trials were mostly run in academic centers with research staff, so the hospital should expect smaller effects. And the business case depends on an estimate of the variable cost of a readmission that the finance department should confirm. None of these limits argues against acting, but together they argue for measuring carefully and adjusting as results arrive.

Employment Portfolio: What This Capstone Demonstrates

The capstone doubles as the core of an employment portfolio for healthcare administration roles such as care management coordinator, quality analyst or operations manager. It shows six competencies an employer can verify. Problem definition: turning a vague concern about readmissions into a measured gap with a one-sentence problem statement. Evidence use: finding, appraising and applying meta-analyses and a trial, including one that contradicted the first assumption. Data analysis: using record data, stratification, a Pareto ranking and a decision matrix. Financial reasoning: costing options and building a business case with a check at half the target. Implementation planning: phases, roles, risks and decision points. Communication: an executive summary that a chief nursing officer could read in two minutes.

The portfolio will contain four artifacts drawn from the capstone: the one-page executive summary, the decision matrix, the run chart template for the evaluation, and a two-page implementation plan. Each artifact uses the composite hospital, so no patient or employer information is disclosed.

Presenting the Work to Employers

In a résumé, the capstone becomes two or three lines stated as results of analysis rather than claims of outcomes, since the plan has not been carried out: for example, analyzed twelve months of discharge data for 762 heart failure patients and identified appointment booking before discharge as the strongest factor in seven-day follow-up; designed a costed four-part transition bundle with a business case showing avoided costs of about three times program cost at target. In interviews, the most useful story is the moment the rideshare trial contradicted the original plan, because it shows willingness to follow evidence over a first idea. A short presentation of the executive summary and the decision matrix, no more than five slides, can accompany applications for roles that ask for work samples. Finally, the capstone suggests a next step for professional growth: learning the hospital's readmission data systems well enough to run this kind of analysis on other conditions.

References

Centers for Medicare & Medicaid Services. (2026, September 21). Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp

Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., & Curtis, L. H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA, 303(17), 1716-1722. https://doi.org/10.1001/jama.2010.533

Van Spall, H. G. C., Rahman, T., Mytton, O., Ramasundarahettige, C., Ibrahim, Q., Kabali, C., Coppens, M., Haynes, R. B., & Connolly, S. (2017). Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: A systematic review and network meta-analysis. European Journal of Heart Failure, 19(11), 1427-1443. https://doi.org/10.1002/ejhf.765