| Course | HCR 426 Health Care Coordination Capstone |
|---|---|
| Module | Module 3 |
| Paper type | Capstone solution paper |
| Length | About 871 words, 6 pages |
| Format | APA 7 student paper |
| School | Arizona State University |
| Program | BS in Health Care Coordination |
| Updated | October 2026 |
Free sample paper for HCR 426 Module 3
Bridge Home: A Coordinator-Led Discharge Program for a Community Hospital
Student Name
BS in Health Care Coordination, Arizona State University
HCR 426: Health Care Coordination Capstone
Instructor Name
Month Day, Year
Bridge Home: A Coordinator-Led Discharge Program for a Community Hospital
The Issue and Its Impact
Discharge is the point where a patient's care passes from one team to another, and in most hospitals no one is accountable for the whole handoff (Bodenheimer, 2008). The cost of that gap is measurable. In a Boston cohort, nearly one patient in five suffered an injury from medical care within weeks of going home, most often from a medicine (Forster et al., 2003). Primary care physicians, meanwhile, usually lack the hospital's summary when they first see the patient (Kripalani et al., 2007). Patients bear the harm directly, through return visits, drug reactions and lost confidence. Hospitals bear it through Medicare's readmission penalty, and payers bear it through stays that should not have happened. Readmissions for the conditions Medicare targets did drop after the penalty arrived, yet roughly one patient in six still returned within a month in 2015 (Zuckerman et al., 2016).
The Role of the Health Care Coordinator
In Bridge Home the coordinator owns the handoff from the moment a high-risk patient is identified until the first clinic visit is complete. The coordinator flags patients, assigns a discharge advocate, confirms that a follow-up appointment exists before the patient leaves, makes sure the discharge summary reaches the clinic and keeps a log of every patient's 30-day course. The coordinator is also the single number that patients, families, clinic staff and home health agencies can call. Programs that cut admissions in Medicare's demonstrations shared this kind of hub role, with information flowing through one person rather than scattering among many (Brown et al., 2012).
The Solution: Bridge Home
Bridge Home bundles several activities, because reviews of readmission programs find that single steps rarely work on their own (Hansen et al., 2011) and that programs with more components and more support for patients' self-care do better (Leppin et al., 2014). The core comes from Project RED, the randomized trial critiqued in Module 2.
Table 1 lists the six components, what happens in each and the study behind it.
| Component | What happens | Evidence |
|---|---|---|
| Risk flag | Coordinator lists medical-unit adults who were admitted, or treated in the emergency department, at least once in the prior half year | Project RED helped most in this group (Jack et al., 2009) |
| Discharge advocate | A nurse teaches from a personal booklet in English or Spanish, reconciles medicines and books the follow-up visit | Core of the Project RED bundle (Jack et al., 2009) |
| Summary to the clinic | Booklet and discharge summary sent to the primary care office before the first visit | Closes the information gap (Kripalani et al., 2007) |
| Pharmacist call | Bilingual pharmacist phones on day two to four to review each medicine | Drug events are the most common injury after discharge (Forster et al., 2003) |
| Home visit | Community health worker visits within a week for patients with three or more admissions in a year | Support for self-care strengthens programs (Leppin et al., 2014) |
| Coordinator log | 30-day follow-up of every enrolled patient | Hub role in successful programs (Brown et al., 2012) |
What the Evidence Warns Against
Not every coordination program pays off. Of 15 Medicare programs that relied mainly on nurses calling patients, 13 did not lower hospitalizations and none saved money once fees were counted (Peikes et al., 2009). Bridge Home therefore keeps its most important contacts in person, at the bedside and in the home, and uses the telephone only to reinforce what was already taught. Newer trials have also shown smaller benefits than older ones, so the plan assumes a modest reduction in returns rather than the 30% seen in Project RED.
Implementation
Phase 1, months 1 to 3: hire a coordinator, train two discharge advocates and one community health worker, translate the booklet into Spanish with patient reviewers, build the risk flag into the electronic record and agree with three affiliated clinics on how summaries and appointments will be exchanged. Phase 2, months 4 to 9: run the program on two medical units and review the log every two weeks. Phase 3, months 10 to 12: extend to the remaining medical units if the measures improve. Staff time is the main cost. Avoided readmission penalties and Medicare's transitional care management codes, which pay clinics for timely post-discharge visits, can offset part of it.
Measures
Outcome: emergency visits and readmissions within 30 days for enrolled patients, compared with similar patients on units that have not yet started. Process: percent with a booked appointment at discharge, summary received by the clinic before the visit and pharmacist call completed within four days. Patient experience: a three-question survey on understanding of medicines. Equity: every measure reported by preferred language and by race and ethnicity, so that a gap for Spanish-speaking patients is visible early.
The Infographic
The companion infographic, "Going Home: Four Things to Know," shows patients and families their medicines, the warning signs that mean a call, the date of their clinic visit and the Bridge Home number, in large type with simple icons, in English and Spanish.
Conclusion
Unsafe discharges injure patients and cost hospitals and payers money. A coordinator-led program built from a tested bundle, adapted for the hospital's own patients and measured honestly, is a realistic step toward safer transitions.
References
Bodenheimer, T. (2008). Coordinating care: A perilous journey through the health care system. New England Journal of Medicine, 358(10), 1064-1071. https://doi.org/10.1056/NEJMhpr0706165
Brown, R. S., Peikes, D., Peterson, G., Schore, J., & Razafindrakoto, C. M. (2012). Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Affairs, 31(6), 1156-1166. https://doi.org/10.1377/hlthaff.2012.0393
Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007
Hansen, L. O., Young, R. S., Hinami, K., Leung, A., & Williams, M. V. (2011). Interventions to reduce 30-day rehospitalization: A systematic review. Annals of Internal Medicine, 155(8), 520-528. https://doi.org/10.7326/0003-4819-155-8-201110180-00008
Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007
Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831
Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K., Wang, Z., Erwin, P. J., Sylvester, T., Boehmer, K., Ting, H. H., Murad, M. H., Shippee, N. D., & Montori, V. M. (2014). Preventing 30-day hospital readmissions: A systematic review and meta-analysis of randomized trials. JAMA Internal Medicine, 174(7), 1095-1107. https://doi.org/10.1001/jamainternmed.2014.1608
Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA, 301(6), 603-618. https://doi.org/10.1001/jama.2009.126
Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine, 374(16), 1543-1551. https://doi.org/10.1056/NEJMsa1513024
What the HCR 426 Module 3 instructions ask for
HCR 426 ends with the Final Project, a paper paired with an infographic for 20 points, which makes it the heaviest single grade in the capstone. The syllabus asks the paper to discuss how your chosen issue affects the health care system and what role the health care coordinator plays, and the course description sets the goal of a real-world coordination solution that works as a catalyst for change, whether by making transitions safer and more patient-centered, lowering readmissions, improving safety or reducing cost. The bibliography, the critique, the VoiceThread and the pamphlet all lead here, so the final paper should draw visibly on them. Plan sections for the impact of the issue, the coordinator's role, the solution itself, how it would be rolled out and how success would be measured, and leave room to describe the infographic and how patients would use it.
How this HCR 426 Module 3 example is built
The sample opens by measuring the issue's impact on patients, hospitals and payers with sources the bibliography already appraised. The coordinator's role is described in concrete daily tasks rather than a job title. The solution section explains why the program is a bundle and then lays out six components in a table, each with its evidence. A short section on what the evidence warns against shows why the program keeps key contacts face to face and why it expects a modest effect. Implementation follows in three dated phases with a note on cost and payment, the measures cover outcome, process, patient experience and equity, and a brief description of the infographic ties the paper to its companion piece before a two-sentence conclusion.
Where the marks sit in the HCR 426 Module 3 rubric
Canvas scores the Final Project out of 20 points, paper and infographic together. A capstone paper earns its marks by showing the issue's impact with evidence, defining the coordinator's part in the solution in practical terms, building the solution from studies rather than intuition, planning a rollout someone could actually approve, choosing measures that would reveal both success and inequity and pairing all of it with an infographic patients can follow. It loses marks when the solution is a wish list with no source behind each part, when the coordinator's role stays vague, when costs and staffing are skipped and when the measures could not be collected. Because this is the last paper of the degree's coordination sequence, readers also look for continuity with the student's own earlier capstone work.
HCR 426 Module 3 help from the desk
Begin with your bibliography and critique open beside you; most of your evidence is already gathered and appraised. Put the solution into a table that pairs each component with its source, then use the prose to explain your choices. Name the staff, put a figure on the cost and say where the money comes from. Choose measures you could collect from records your organization already keeps, and include at least one that is reported by language or race. Design the infographic for patients, in plain words and large type, and ask a neighbor or relative with no health training to read it back to you. For a second pair of eyes on the full capstone before the deadline, the desk can read it against the course description's goals.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Arizona State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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- HCR 422 Module 1: History of U.S. Health Insurance, Medicare, Medicaid and Reform Paper
- HCR 420 Module 2: Stages of Conflict Paper
HCR 426 Module 3 questions, answered
Where can I find a free HCR 426 Module 3 sample paper?
This page has a full HCR 426 Module 3 sample: Bridge Home, a coordinator-led discharge program for a community hospital.
What does the HCR 426 final project include?
A paper on the issue's impact and the coordinator's role with a real-world solution, plus a companion infographic.
How many points is the HCR 426 final project?
Twenty points for the paper and infographic together, the heaviest single grade in the course.
Should the HCR 426 final paper use my earlier capstone work?
Yes. The bibliography and critique supply most of the evidence, and readers look for that continuity.
What measures should a care coordination solution include?
An outcome such as 30-day returns, process measures, a patient experience question and results split by language or race.