WGU D028 TASK 1 - CARE TRANSITION PLAN FOR PREVENTING
READMISSIONS | ACCURATE AND VERIFIED | 2026 UPDATE
Author Name: Andrea Spears
Leavitt School of Health, Western Governors University
D028: Quality Outcomes in a Culture of Value-Based Nursing Care
Instructor Name: Ilene Gottesfeld
, CPE Record
Activities to be completed Date of Time needed to
Completion complete
Phase 1
Briefly discuss the elements and criteria 5-14-24
used for the CMS HRRP
conditions/procedures payment
reduction plan for readmissions within 30
days of discharge
Develop/propose a Care Transition Plan
for the patient with the condition or
procedure that you chose for your CPE.
Research the evidence-based practices
for effectively transitioning patients from
the hospital (& rehabilitation unit) to
home with the specific focus on
preventing all-cause hospital readmission.
Utilize your textbooks, online resources,
and other sources as needed
Discuss evidence-based practices focused
on preventing all-cause hospital
readmissions
Incorporate individual, community,
system, and social determinants of health
considerations that impact all-cause
readmission and how to prevent them.
Phase 2
Research the evidence-based practices for
effectively transitioning patients from the
hospital (& rehabilitation unit) to home
with the specific focus on preventing all-
READMISSIONS | ACCURATE AND VERIFIED | 2026 UPDATE
Author Name: Andrea Spears
Leavitt School of Health, Western Governors University
D028: Quality Outcomes in a Culture of Value-Based Nursing Care
Instructor Name: Ilene Gottesfeld
, CPE Record
Activities to be completed Date of Time needed to
Completion complete
Phase 1
Briefly discuss the elements and criteria 5-14-24
used for the CMS HRRP
conditions/procedures payment
reduction plan for readmissions within 30
days of discharge
Develop/propose a Care Transition Plan
for the patient with the condition or
procedure that you chose for your CPE.
Research the evidence-based practices
for effectively transitioning patients from
the hospital (& rehabilitation unit) to
home with the specific focus on
preventing all-cause hospital readmission.
Utilize your textbooks, online resources,
and other sources as needed
Discuss evidence-based practices focused
on preventing all-cause hospital
readmissions
Incorporate individual, community,
system, and social determinants of health
considerations that impact all-cause
readmission and how to prevent them.
Phase 2
Research the evidence-based practices for
effectively transitioning patients from the
hospital (& rehabilitation unit) to home
with the specific focus on preventing all-
