Degree Name
Nursing Practice, DNP
Publication Date
2-2026
First Advisor
Amber Calendar
Second Advisor
Veronica Arredondo
Abstract
The underutilization of Transitional Care Management (TCM) services in primary care significantly contributes to preventable hospital readmissions and revenue loss. Despite established Centers for Medicare & Medicaid Services (CMS) guidelines, execution often fails due to knowledge gaps among frontline staff. This quality improvement project addressed low TCM task completion rates by implementing a structured educational intervention for medical assistants (MAs). The purpose was to evaluate whether targeted training improves timely patient follow-up, visit scheduling, and billing accuracy. The project utilized Kotter’s 8-Step Change Model to guide organizational change and the Health Belief Model to address behavioral barriers. A quantitative, quasi-experimental pre-post design was employed with 11 MAs at a family practice clinic. Using the Plan-Do-Study-Act (PDSA) framework, a CMS-based training program was delivered to standardize workflows. Data were collected using the TCM Knowledge and Self-Efficacy Survey and electronic health record audits. Results indicated statistically significant improvements across all key metrics. Mean knowledge scores increased from 8.00 to 12.73 (p < .0001), and self-efficacy rose from 2.75 to 4.08 (p < .0001). Critical process measures also improved, with timely call completion increasing from 42.5% to 72.3% (p < .0001) and billing compliance rising from 27.6% to 63.8% (p < .0001). These findings demonstrate that structured education significantly enhances MA competency and process adherence, offering a viable strategy for improving care coordination and financial sustainability in primary care.
Rights Management
This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
Recommended Citation
Assick, Oben, "Quality Improvement Project: Improving Transitional Care Management (TCM) Follow-Up Through Medical Assistant Education" (2026). Doctor of Nursing Practice Projects. 312.
https://arch.astate.edu/dnp-projects/312
