The Project

With backing from the Patient-Centered Outcomes Research Institute (PCORI), a team from Florida Atlantic University set out to develop a decision guide to help residents and their families understand the reasons to stay in the nursing home or go to the hospital when an acute change in condition occurs. They conducted 270+ interviews with residents, families and providers in 19 Florida nursing homes to incorporate their perspective and concerns in this Guide.

With support from the states of CMS Region IV (AL, GA, FL, KY, MS, NC, SC, TN) a pilot project was then rolled out to 16 nursing homes in Region IV. Data on readmissions was collected for three months before and after implementation of the Guide. Training videos, case studies and other materials were developed to support use of the Guide. The pilot nursing homes achieved 31% reduction. in hospital readmissions.

In the second phase of the project, the team offered 20 training workshops across Region IV and a series of webinars to over 1300 participants representing facilities, state agencies, ombudsmen, long-term care organizations, corporations and several interested hospitals. Workshop participants surveyed reported an average 28% reduction in hospital readmissions achieved after implementing the Guide. Ninety-seven percent of them said it was helpful, only 3% said it was not.

The Project Team

The project team has been led by Dr. Ruth Tappen, Professor and Eminent Scholar at the Florida Atlantic University Christine E. Lynn College of Nursing. The team included experienced healthcare professionals, academics, graduate students, administrative professionals, designers and programmers. For further information, please contact Dr. Tappen at or the project email address

Funding for development of original Guide provided by Patient-Centered Outcomes Research Institute (PCORI). Funding for this updated Guide provided by the Eight States of CMS Region IV (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) Copyright Florida Atlantic University