Dissertation
Bridging Hospital and Community Care to Support Patient Needs
University of Iowa
Doctor of Nursing Practice (DNP), University of Iowa
Spring 2026
Abstract
Background: Social drivers of health (SDOH) contribute up to 80% of health outcomes. The Centers for Medicare and Medicaid Services required hospitals to report five domains of social health needs (housing, food, utilities, interpersonal safety, transportation) identified on adult admissions. The Joint Commission's 2026 National Performance Goals for critical access hospitals (CAHs) include assessing health-related social needs and sharing information about community resources. The American Nurses Association 2025 Code of Ethics reinforces nursing's role in social justice. The Community Health Needs Assessment (CHNA) commonly identifies unmet SDOH as priority concerns. Purpose: The purpose of this Doctor of Nursing Practice (DNP) project was to implement a system-level practice change that engaged nurses to increase referrals for unmet social drivers and improve the patient/family experience on care transitions for older hospitalized adults discharged from a critical access hospital to the community. Methods: A literature review supported multi-level leadership engagement through a nurse-leader task force, development of community partnerships, staff education on communication and resource awareness, and use of a referral platform. The project setting was a medical/surgical unit in a 20-bed CAH in west-central Iowa. The Iowa Implementation for Sustainability Framework guided project planning, implementation, and sustainability. Results were measured through an education evaluation, post-event survey, referral tracking, and pre- and post-implementation patient experience data. Findings: Staff materials and education, paired with a Community Organization Presentation and Resource Fair, were held in October 2025. Referrals to targeted organizations increased from baseline. The targeted care transitions survey score increased by over 10%. Additional unanticipated outcomes included higher-than-expected community partner engagement, favorable nursing training evaluation, and a no-cost, HIPAA-compliant referral platform embedded into the hospital website with affiliated clinic referrals. Discussion: This project demonstrates the impact of nurse-led, system-level interventions in strengthening SDOH knowledge and resource awareness, advancing CHNA implementation goals, and community partnerships.
Details
- Title: Subtitle
- Bridging Hospital and Community Care to Support Patient Needs
- Creators
- Randi Boell - University of Iowa
- Contributors
- Harleah Buck (Chair) - University of Iowa
- Resource Type
- Dissertation
- Project Type
- Poster
- Degree Awarded
- Doctor of Nursing Practice (DNP), University of Iowa
- Degree in
- Health Systems/Administration
- Date degree season
- Spring 2026
- Publisher
- University of Iowa
- Number of pages
- 1 page
- Copyright
- Copyright © 2026 Randi Boell
- Language
- English
- Academic Unit
- College of Nursing; Doctor of Nursing Practice Projects
- Record Identifier
- 9985217822202771
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