Nursing PHASE 3 ASSIGNMENT

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Phase I Assignment

Student's name: Yulexis Moreda

Instructor: Aciel Sagrera-Mulen

Course: Nursing Research and Evidence-Based Practice

Date: July 6, 2025

Reducing Hospital Readmissions for Heart Failure Patients

Introduction to the Problem

HF is one of the most common chronic diseases in the United States, especially among older adults. According to Roger (2021), "HF is far more prevalent in older age groups, reaching 4.3% among persons aged 65 to 70 years old in 2012 and projected to increase steadily through year 2030 when the prevalence of HF could reach 8.5%". As Khan et al. (2021) report, "Nearly 1 in 4 heart failure (HF) patients are readmitted within 30 days of discharge and approximately half are readmitted within 6 months". This high readmission rate is a serious issue in healthcare provision, commonly indicating unacceptable transitional care and inadequate post-discharge patient support.

Hospital discharge to home is a sensitive period, especially in the case of HF patients who must deal with multiple self-care and follow-up tasks. Studies indicate that readmissions are generally avoidable with proper transitional care measures. Transitional nursing aims to bridge the care gap by implementing systematic interventions, such as patient education, discharge planning, follow-up phone calls, and coordination with outpatient practitioners. When implemented by nurses, these interventions have been found to decrease hospital readmissions and enhance patient outcomes. The goal of this project is to investigate how nurses' transitional care strategies impact the reduction of preventable hospital readmissions for patients with heart failure.

Identifying the Problem

The most significant problem is the high percentage of 30-day hospital readmissions among patients with heart failure. Transitions are most frequently associated with care fragmentation for hospital-to-home discharge, e.g., poor discharge teaching, medication abuse, failure to follow up on time, and poor patient comprehension of their disease (Sakowitz et al., 2023). Although post-discharge care has been optimized, most hospitals lack the capability to offer uniform, high-quality transitional services for HF patients.

There is also a shortage of standard, evidence-based treatments. Patients are commonly discharged from the hospital with minimal information about their drugs, diet, and warning signs of collapse. Interchanges also among hospital groups and community-based carers are frequently poor, resulting in discontinuity of care. That breakdown significantly enhances the risk of avoidable complications and readmission, which consumes healthcare resources and damages patient well-being.

Significance of the Issue to Nursing

The problem of readmission for heart failure is especially relevant to the field of nursing practice. Nurses are at the forefront of discharge planning and patient education, and their role in transitional care is critical to ensuring that patients are adequately prepared upon hospital discharge. Marques et al. (2022) note that "Outpatient care provided by nurses to patients with HF has been the focus of studies, showing a reduction in hospital readmissions". Advanced practice nurses are also well-suited to facilitate and direct care transition models that encourage communication, track patient progress, and maintain post-discharge adherence to care plans.

High rates of readmission are quality markers of care and are associated with financial penalties in value-based reimbursement systems for care. Nurses are dedicated to acting on these quality markers through evidence-based practice. Transitional care is an outgrowth of the nursing process with a focus on assessment, planning, intervention, and evaluation. Nurses can play a highly influential role in reducing readmissions, improving patient satisfaction, and making the healthcare system more sustainable by taking the lead on transitional care initiatives (Marques et al., 2022).

In addition, transitional care supports nursing's holistic philosophy because it extends beyond the repair of physical well-being to address the emotional, social, and educational health needs of patients. Nurses reassure, explain physicians' orders, and represent the patient's interests throughout the continuum of care. A readmission reduction not only enhances clinical outcomes but also fosters trust and involvement among patients and healthcare providers.

Purpose of the Research

The primary objective of this research is to assess the impact of nurses' transitional care interventions on the 30-day readmission rates of heart failure patients to hospitals. The study will quantify the effectiveness of various interventions, including follow-up phone calls, home visits, telemonitoring, and medication reconciliation, in preventing readmissions. Besides clinical outcomes, the study will assess patients' views of the care provided and nurses' experiences with implementing these strategies.

Knowing which elements of transitional care yield the most beneficial results can enable institutions to allocate resources effectively and emulate successful methods. By identifying where implementation is likely to be least successful, this research can also inform educational and policy initiatives, enabling nurses to deliver high-quality care during transitions of care. Finally, the results will further establish an evidence base supporting safe, patient-oriented care and facilitating professional development for nurses in extended roles.

Research Questions

This research will be informed by a set of guiding questions: What are the most effective nurse transitional care programs to minimize 30-day hospital readmission of heart failure? How do patients assess the quality and efficacy of transitional care services from nurses following hospital discharge? What are nurses' challenges in implementing transitional care among heart failure patients?

Responding to these questions will help construct a deeper understanding of how transitional care can be maximized to meet the needs of vulnerable populations, most critically those with chronic cardiovascular disease.

Master's Essentials that aligned with this topic

This project aligns with several of the Essentials of the American Association of Colleges of Nursing (AACN) Essentials for Master's Education. Essential I, which involves the integration of scientific knowledge from both the sciences and humanities, is evident in comprehending the multifaceted pathophysiology and psychosocial dynamics of heart failure care. Essential II, Organizational and Systems Leadership, emphasizes the design and testing of interventions that necessitate strategic planning, interprofessional collaboration, and quality improvement.

Core IV, Translating and Integrating Scholarship into Practice, is paramount to this study, as it involves the implementation of existing evidence into the practice of practical nursing interventions. Core VI, Health Policy and Advocacy, is met by confronting systemic barriers and policy dilemmas related to transitional care services. Finally, Core IX, Master ''s-Level Nursing Practice, is confronted by addressing leadership, clinical decision-making, and care coordination, all key elements of advanced nursing practice in transitional care facilities.

Conclusion

The challenge of high hospital readmission of patients with heart failure is of concern to the healthcare of today, one that nurses can solve. Transitional care nursing is a solution whose time has arrived, providing continuity, safety, and education during the hazardous post-discharge period. This study aims to reiterate the importance of nurse intervention in enhancing patient outcomes and contributing to a more efficient, patient-focused healthcare system. By identifying effective interventions and reviewing implementation barriers, this study contributes to the advancement of nursing practice and the delivery of high-quality care for individuals with chronic illnesses.

References

Khan, M. S., Sreenivasan, J., Lateef, N., Abougergi, M. S., Greene, S. J., Ahmad, T., … & Butler, J. (2021). Trends in 30-and 90-day readmission rates for heart failure.  Circulation: Heart Failure,  14(4), e008335. https://www.ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.121.008335

Marques, C. R. D. G., de Menezes, A. F., Ferrari, Y. A. C., Oliveira, A. S., Tavares, A. C. M., Barreto, A. S., … & Santana-Santos, E. (2022). Educational nursing intervention in reducing hospital readmission and the mortality of patients with heart failure: a systematic review and meta-analysis.  Journal of Cardiovascular Development and Disease,  9(12), 420. https://www.mdpi.com/2308-3425/9/12/420

Roger, V. L. (2021). Epidemiology of heart failure: a contemporary perspective.  Circulation research,  128(10), 1421–1434. https://www.ahajournals.org/doi/full/10.1161/CIRCRESAHA.121.318172

Sakowitz, S., Madrigal, J., Williamson, C., Ebrahimian, S., Richardson, S., Ascandar, N., … & Benharash, P. (2023). Care fragmentation after hospitalization for acute myocardial infarction.  The American Journal of Cardiology,  187, 131–137. https://www.ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.121.008335

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Phase II Assignment

Student's name: Yulexis Moreda

Instructor: Aciel Sagrera-Mulen

Course: Nursing Research and Evidence-Based Practice

Date: July 24, 2025

Reducing Hospital Readmissions in Heart Failure Patients through Structured Discharge Planning and Patient Education

Brief Literature Review

HF causes a substantial number of hospitalizations and readmissions of older adults, as it is one of the primary causes of both hospitalization and readmission. The transition from Hospital to home is an important opportunity for intervention, especially in terms of successful discharge planning and patient education. This literature consistently advocates for the effectiveness of structured discharge in helping to reduce the rate of hospital readmission among patients with HF.

Bradley et al. (2022) conducted an informative review of discharge planning interventions and their impact on patient outcomes. The authors state that “A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received” (Bradley et al., 2022). To support the above-mentioned ideas, the study noted that customized discharge planning may significantly decrease readmission levels and improve patient satisfaction. Key aspects, such as involving the family and patient, early introduction of discharge planning, and follow-up in the post-discharge period, are linked to better outcomes.

On the other hand, Browder and Rosamond (2023) specifically addressed socioeconomic factors in HF readmissions. They discovered that the low socioeconomic patients are disproportionately disadvantaged by ineffective discharge planning and the absence of access to post-discharge services. The interventions that overcome these barriers, tailored to the needs of patients, including transportation assistance, medications, and telehealth, showed potential in reducing readmission risks. According to the authors, “there was a reduction in readmissions after the implementation of HRRP” (Browder & Rosamond, 2023).

Burse (2024) assessed a discharge planning and education program in the clinical environment of a real-life hospital and found a significant reduction in 30-day readmission. Her results support the significance of properly organized education under nursing leadership that focuses on adherence to medications, monitoring symptoms, and conducting follow-up visits. The involvement of discharge planners in multidisciplinary care teams was also identified as a key strategy for improving patient outcomes.

Fatani et al. (2025) examined the effect of discharge planning teams on the length of stay and readmission outcomes in neurological patients. Although this study is not specific to HF, it provides an argument in favor of the generalizability of discharge principles in diagnosis. The existence of a specialized team was associated with a reduced overall length of stay and readmission, supporting the argument that organizational factors had a significant impact on the success of discharges.

Similarly, a systematic review carried out by Wu et al. (2024) on nurse-led HF clinics noted a consistent decrease in patient hospitalization and improved self-management. All the clinics provide extensive education, effective drug management, and prompt symptom deterioration management early on. Although the study was not conducted within the Hospital, it confirms the value of nurse-led patient education in preventing readmissions.

The body of this research, taken together, provides a solid evidence foundation regarding the value of structured discharge planning and specific educational work as primary tools to prevent HF readmission.

Research design and study methods

The present study will employ a quasi-experimental pre-post research design to examine the effectiveness of an enhanced discharge planning and education protocol among patients with heart failure. The context in which the intervention will be delivered is a mid-sized urban hospital that accepts a diverse population.

The research will consist of two stages: the baseline data collection stage and the intervention stage. In the baseline phase, information on 30-day readmissions, including those of HF patients in the 6 months preceding the intervention, will be obtained retrospectively. During the intervention stage, a standard discharge planning and education program will be implemented for all patients who have been admitted based on their primary diagnosis of heart failure.

The intervention will comprise interventional discharge planning initiated at the time of admission, a discharge checklist, medication reconciliation, patient-centered education to learn how to manage heart failure, scheduling of follow-up appointments before discharge, and a post-discharge telephone call made by a nurse within 72 hours. The education part will rely on the teach-back technique to ensure the patient. Written materials, medication calendars, and symptom checking logs will be provided to patients.

The significant results will include rates of readmission over 30 days, patient satisfaction, and medication compliance, which will be assessed through pharmacy refill records. Secondary endpoints will include hospitalizations and emergency department visits. The electronic health records of the patients (EHRs), the survey, and the telephone interviews will be used to gather data.

“The hospital Institutional Review Board (IRB)” will ethically approve the study, and an informed consent will be signed by all participants. This design ensures internal validity while also facilitating real-world applicability and minimizing disruption to standard care practices.

Sampling Methodology

In the study, the non-randomized convenience sampling technique, which fits the quasi-experimental design, will be employed. Potential participants will be adult patients (18 years old and beyond) who were admitted to the Hospital with HF as the primary diagnosis in the internal medicine or cardiology departments of the Hospital.

Criteria of inclusion will take the form of: (1) proven heart failure as per the ICD-10 coding and through clinical assessment of the patient, (2) has been discharged home or to self-care, and (3) able to provide informed consent. There will be exclusion criteria including: (1) patients who have been transferred to long-term care or hospice, (2) patients with extreme cognitive impairment with no available caregiver who may attend education, and (3) non-English speaking patients without an interpreter.

A power analysis will be conducted to determine the sample size required to detect a statistically significant decrease in readmission rates with a power of 80% and an alpha level of 0.05. Using the data from the past, it is projected that an estimated sample size of 200 patients per group (pre-intervention and post-intervention) will be recorded.

Although the sampling plan may limit the generalizability of the findings to other populations, it provides viable access to participants in the target demographic. It ensures a reasonable level of integration within the prevailing hospital framework. Mixed methods will be employed to gather both quantitative and qualitative opinions related to readmission rates (admission rates, medication adherence), as well as patient perceptions towards the discharge process.

Necessary Tools

A series of tools will be utilized in the study for collecting and evaluating data. The tools to be used for collecting primary data will include the electronic health record audit template, validated patient satisfaction surveys, and structured interview guides. The “Morisky Medication Adherence Scale (MMAS-8)” is a rated instrument that will serve as a tool in assessing medication adherence in chronic disease studies, as it is a valid instrument.

The checklist for discharge education will become one of the main tools for ensuring the consistency of interventions. Some of the items it will contain include learning about dietary prohibitions, tracking symptoms, understanding the side effects of medications, knowing when to call in, and scheduling follow-up visits. The nurses will record the list of checklist completions in EHR.

The teach-back method will be used to assess patient comprehension. To gauge the patients' comprehension, nurses will require them to recall major concepts addressed in the discharge education process. The teach-back assessment rubric will be used to score responses and document them in the patient's medical record.

The follow-up calls will be conducted using a structured script that evaluates the patient's symptoms, medication use, follow-up visits, and any impediments to care. Information provided during these calls will be used to measure current compliance and identify initial signs of disengagement.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey will be used to measure patient satisfaction with the discharge process, specifically regarding discharge information and care transition items. Such data will be summed up and analyzed before and after the intervention.

SRSP software will be used in data analysis. Demographic and clinical characteristics will be summed up using descriptive statistics. Chi-square tests, along with logistic regression, will be used to evaluate the differences in outcomes between the pre- and post-intervention populations using inferential statistics.

Illustrations

Morisky Medication Adherence Scale (MMAS-8)

Question	Yes	No
Do you sometimes forget to take your medications?
Over the past two weeks, was there a day when you skipped taking your medications?
Have you ever stopped taking medication without notifying the doctor?
Do you sometimes forget your medications when you travel?
Did you take your medication yesterday?
Do you sometimes stop taking your medication when you feel better?
Do you find it challenging to stick to your treatment plan?
How often do you have trouble remembering to take your medication?

Scoring

Items 1–4, 6, 7: Yes = 1, No = 0

Item 5: Yes = 0, No = 1

Item 8: Score based on the option selected

Interpretation:

Total score 0 = High adherence

Score 1–2 = Medium adherence

Score ≥3 = Low adherence

Conclusion

Heart failure readmissions are another ongoing issue that, in many cases, may be addressed with the help of enhanced discharge planning and education. The evidence in the literature is overwhelming regarding the use of structured discharge protocols and nurse-led education as an effective strategy to reduce readmissions and positively impact patient outcomes. This evidence-based quasi-experimental research, employing a rigorous methodology, is proposed to determine the effect of a holistic discharge planning program on 30-day readmission rates, patient satisfaction, and medication adherence. With the use of validated instruments and effective interventions, the study can provide policy and clinical practice guidelines for the transition of care in patients with heart failure.

References

Bradley, D. C., Lannin, N. A., Clemson, L., Cameron, I. D., & Shepperd, S. (2022). Discharge planning from the Hospital. Cochrane Database of Systematic Reviews, 2022(2). https://doi.org/10.1002/14651858.cd000313.pub6

Browder, S. E., & Rosamond, W. D. (2023). Preventing Heart Failure Readmission in Patients with Low Socioeconomic Position. Current Cardiology Reports, 25(11). https://doi.org/10.1007/s11886-023-01960-0

Burse, C. (2024). Reducing Congestive Heart Failure Readmissions through Discharge Planning and Education. The Aquila Digital Community. https://aquila.usm.edu/cgi/viewcontent.cgi?article=1295&context=dnp_capstone

Fatani, A., Alzebaidi, S., Alghaythee, H. K., Alharbi, S., Bogari, M. H., Salamatullah, H. K., Alghamdi, S., & Makkawi, S. (2025). The role of the discharge planning team on the length of hospital stay and readmission in patients with neurological conditions: A single-center retrospective study. Healthcare, 13(2), 143. https://doi.org/10.3390/healthcare13020143

Wu, X., Li, Z., Tian, Q., Ji, S., & Zhang, C. (2024). Effectiveness of nurse-led heart failure clinic: A systematic review. International Journal of Nursing Sciences, 11(3), 315–329. https://doi.org/10.1016/j.ijnss.2024.04.001