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Decreasing Congestive Heart Failure Readmission

Specialty Focus

The purpose of DNP program is to train nurses on nursing leadership and evidence-based practice. The program focuses on key competencies in advanced nursing practice. Essential competencies for nurse students depend on practice specialty; for instance, the curriculum for students training in nurse leadership will have more content on systems management compared to the curriculum for APNs.

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My specialty focus is systems/organizational leadership role and my advanced nursing role specialization is executive nursing administration. My scholarly nursing practice focuses on elderly patients diagnosed with congestive heart failure (CHF) and due for readmission.

Phenomenon of Interest

My phenomenon of interest is congestive heart failure (CHF). CHF is a common condition diagnosed in elderly patients (65 years and older) after discharge that often leads to readmission. As an APN involved in geriatric care, am particularly interested in strategies or interventions that decrease CHF readmission in this patient population.

Past studies have established that elderly patients coping with one or more chronic medical conditions are vulnerable to post-discharge conditions during home transitions. A study by McCauley, Bixby and Naylor (2006) focused on APN strategies that can decrease re-admission and increase patient outcomes.

The researchers found that combination of personal factors such as cognitive or functional impairment and system factors such as lack of patient education and poor provider-patient relationships contribute to poor patient outcomes (p. 312). Among readmission-reduction strategies identified were caregiver or family education on symptom management, enhanced patient-caregiver relationship through communication and medication compliance interventions (McCauley, Bixby & Naylor, 2006, p.310). Thus, evidence-based APN strategies that address the organizational and patient factors are important in reducing CHF readmission.

The prevalence rate of CHF has increased over the past few years with great implications on hospitalization costs; the annual expenditure stands at $10 billion for CHF diagnosis and treatment (McCauley, Bixby & Naylor, 2006, p.312). Also, CHF-related mortality rates are high; in 2002, over 260,000 deaths in the United States were directly linked to heart failure-related complications.

Furthermore, CHF readmission rate is high and contributes to poor patient outcomes. Thus, strategies to decrease readmission must address the risk factors that lead to re-hospitalization shortly after discharge.

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Hamner and Ellison (2005) investigated the predictors of readmission within six months after discharge from an acute care facility. They found that within six months, 40% of discharged patients, experienced heart failure-related symptoms that lead to readmission. They identified the risk factors as: the failure to consult a cardiologist in the first admission; co-morbidities like pulmonary hypertension; medical cover (Medicare); and patient economic status.

Prior readmission, old age, severity of the condition, prior admission and length of hospital stay also influenced the readmission rate. Thus, by understanding the different care plans, their outcomes, as well as the readmission predictors, heart failure nurses can develop discharge care plans that would decrease readmission.

Research evidence shows that to prevent ‘avoidable’ readmission providers should implement the following strategies: adequate provider-patient communication; increasing medication compliance; preventing early discharge; and proper care transition management. A randomized clinical trial by Naylor et al. (2004) examined an Advanced Practice Nurse-led transitional care plan lasting three months after discharge.

They found that a well-planned strategy for transitional care “increased the length of time between discharge and readmission, reduced the number of re-hospitalizations and decreased healthcare costs” (Naylor et al., 2004, p.677). Readmission was lower in the intervention group compared to the control group (47.5% vs. 61.2%). They concluded that an evidence-based transitional care intervention has the potential to cut economic costs and increase clinical outcomes for elderly patients with heart failure.

Among the transitional care interventions for outpatient settings include telephone follow-ups by APN to check medication compliance. Williams, Akroyd and Burke (2010) examined post-discharge program that involved nurse-directed transitional care. They found that follow-ups and home visits by heart failure nurses improved patient outcomes resulting to lower readmission rates. The discharged patients felt satisfied and supported by the discharge process; it enhanced their self-efficacy in symptom management.

Thus, nurse-led discharge can decrease the length of hospital stay and readmission and “enhance patient satisfaction with the post-discharge experience” (Williams, Akroyd & Burke, 2010, p.1404). Also, transitional care should involve a multidisciplinary team in diagnosis and treatment of the patient to ensure optimal health outcomes and decrease delayed discharges.

Another study by Brandon, Schuessler, Ellison and Lazenby (2009) examined the effects of a post-discharge intervention (APN-directed telephone education) to reduce readmission. They found that this intervention had a positive impact on HF patients’ health outcomes and reduced readmission among the intervention group compared to control group (usual care).

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The 30-minute long, bi-weekly telephone calls educated discharged HF patients on self-care, healthy habits, symptom management and emphasized the usefulness of medication adherence. APNs involved in post-discharge care should make sure that HF patients have access to therapy for symptom management. The APN-patient interaction requires that the nurse possesses specialized skills in consultation, clinical care and collaboration are important to meet the learning and cultural needs of the patient.

Tele-monitoring of the patients’ adherence to treatment regimens and ability to note and respond to HF symptoms is important in the APN-patient interactions. Dahl and Penque (2002) also emphasize the role of APN-directed discharge interventions. They argue that APNs are better-positioned to head post-discharge programs for HF patients who need close clinical monitoring. They recommend that APN-led interventions should support and educate the patient on various issues to enhance patient’s health in transitional or home settings and decrease readmission.

Although much evidence available on the effectiveness of post-discharge and transitional interventions in reducing HF readmission, gaps still exist between research, policy and actual practice. From the literature reviewed, telephone follow-up, self-care training of HF patients and PN-led interventions are key transition strategies that can lower HF patient readmission in hospital. Further research should focus on pre-discharge interventions as well as care practices that can reduce HF readmission.

Home-Based CHF Symptom Management Model

According to Hall and Roussel (2013), scholarly clinical practice begins with identification of the problem of interest, evidence-based research, review of relevant literature and integration of the research findings into actual practice. In 2012, I developed a home-based model of care for elderly patients discharged from hospitals and implemented it JWS hospital in Ohio.

The model involved a multidisciplinary team consisting of: APNs, community care agencies; specialty trained geriatric care nurses; and physicians or cardiologists. The model encompasses three key steps; first, the geriatric care nurses uses a validated CHF instrument to assess for signs and symptoms of CHF as well as the risk. After determining the risk, the APN arranges for bi-weekly home visits, whereby he/she is educated the patient on medication compliance and symptom management.

The third step involves cardiologists who visit patient homes for home-based evaluations, CHF diagnoses and therapy recommendations. The details of the consultations are then sent to the primary care physician for further assessment.

The CHF Symptom Management Model follows involves various interventions based on the severity of the patient’s symptoms as determined in the first evaluation. The interventions are implemented using a multi-disciplinary team. I developed a clear protocol, based on research evidence, for implementation of the interventions; it outlines the level of collaboration, in the short-term, between the care nurses and the physicians.

It details the essential skills that the patient should be taught to improve self-care and the teaching techniques for the 8-week intervention program. The protocol also provides for comprehensive cardiac evaluations by a specialist to determine CHF risk. Additionally, an evidence-based predictive mathematical model, which incorporates predictors of CHF condition, was developed and involved in the identification of elderly patients who are “at risk” of CHF.

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The evaluation component of this evidence-based predictive model was the topic of my Doctor of Nursing Practice (DNP). Harris et al (2011) states that evidence-based practice should involve strategies for evaluating the program to determine its success. Exactly one year after the implementation, the project has served 700 patients and has spread to other hospitals. The results from this project have shown a decline in CHF readmission, implying that this intervention is largely effective.

Also, the costs associated with readmission have declined and positive health outcomes realized. The success of this intervention shows that readmission could be reduced through evidence-based practice. Through my DNP scholarly project, I gained important skills and knowledge to evaluate and integrate this model in any health care settings.


Evidence-based practice must involve both scientific research and theory. It is the nursing theory that creates opportunities for analysis of a phenomenon of interest. In this paper, my phenomenon of interest is a CHF readmission among elderly patients. CHF readmission is both costly and high among elderly patients.

Interventions to reduce CHF readmission have been proposed and implemented with varying degrees of success. After reflecting on this phenomenon, I was able to develop an evidence-based model that later evolved into my DNP scholarly project. This program has achieved great success since its implementation in 2012.


Brandon, A., Schuessler, J.B., Ellison, K., & Lazenby, B. (2009). The effects of an advanced practice nurse led telephone intervention on outcomes of patients with heart failure. Applied Nursing Research, 22(6), 1–7.

Dahl, J., & Penque, S. (2002). APN Spells Success for a Heart Failure Program. Nursing Management, 33(2), 46-49.

Hall, H., & Roussel, L. (2013). Evidence-based practice, an integrative approach to research, administration, and practice. Sudbury, MA: Jones & Bartlett Learning.

Hamner, B., & Ellison, K. (2005). Predictors of hospital readmission after discharge in patients with congestive heart. Heart & Lung, 34(4), 231-238.

Harris, J. L., Roussel, L., Walters, S. E., & Dearman, C. (2011). Project planning and management, a guide for CNLs, DNPs, and Nurse Executives. Sudbury, MA: Jones and Bartlett Learning.

McCauley, K., Bixby, M., & Naylor, D. (2006). Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure. Disease Management, 9(5), 302-310.

Naylor, M., Brooten, A., Campbel, R., Maislin, G., McCauley, K., & Schwartz, J. (2004). Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial. Journal of the American Geriatrics Society, 52(2), 675-684.

Williams, G., Akroyd, K., & Burke, L. (2010). Evaluation of the transitional care model in chronic heart failure. British Journal of Nursing, 19(22), 1402-1407.

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