Paper Type

Doctoral Dissertation


Brooks College of Health

Degree Name

Doctor of Clinical Nutrition (DCN)


Nutrition & Dietetics

NACO controlled Corporate Body

University of North Florida. Department of Nutrition & Dietetics

First Advisor

Dr. Lauri Wright

Second Advisor

Dr. Andrea Arikawa

Third Advisor

Dr. Chetan Dodhia

Fourth Advisor

Dr. Sheri Lewis


The topic of Transitions of Care (TOC) has been investigated by physician and nursing professions for years, while only more recently by nutrition professionals. Registered Dietitians are not always involved in TOC planning. RDs can play an important role in TOC by communicating patients’ nutrition information across health care settings, especially for patients with malnutrition. The primary aim was to use a CDC based process evaluation to evaluate if a case management, nursing focused care transitions framework, adapted for a TOC nutrition intervention, can result in a successful intervention implementation. The secondary aim was to use a CDC outcomes evaluation, to evaluate if the number of unplanned hospital readmissions within 30-days from hospital discharge is lower in the TOC nutrition intervention group compared to the comparison group, and if the nutrition status of the intervention participants improved by the end of the 5-week intervention. The primary investigator compiled retrospect patient data who were admitted to Lawrence General Hospital (LGH) during the time of November 2019 through June 2019. From this data set, the comparison group, the number of malnourished patients, and their readmission percent was calculated. A mixed-methods study design included qualitative, quantitative, and quasi-experimental pre/post intervention methods. Patients who were admitted to LGH during a 6-month period starting from the last week in July 2021, through the last week of January 2022, who agreed to participate, were enrolled in a 5-week TOC nutrition intervention. Due to the small sample size (n=21) of patients enrolled, data was analyzed with caution. There was no difference in hospital readmissions between groups. Nutrition status did improve among participants in the intervention group (n=13). The outcomes support the need to integrate a RD as part of TOC multidisciplinary team, especially for patients with malnutrition to improve health outcomes.