PHASE 5 PP

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Phase IV Results

Student's name: Yulexis Moreda

Instructor: Aciel Sagrera-Mulen

Course: Nursing Research and Evidence-Based Practice

Date: August 16, 2025

Reducing Hospital Readmissions for Heart Failure Patients

Abstract

Heart failure (HF) is a leading cause of hospital readmissions in the United States, particularly among older adults, with nearly one in four patients readmitted within 30 days of discharge (Dhaliwal & Dang, 2024). Such high rates are most likely provoked by disconnected care, inappropriate discharge education, and post-discharge follow-up. The project was to investigate how nurse-led transitional care interventions, namely enhanced discharge planning and patient education, affected the rate of 30-day readmissions of HF patients.

Phase I made it possible to define the scope and nursing importance of the problem, which illustrated the role of nurses in discharge planning, patient education, and care coordination. This was to assess follow-up calls, visits at home, telemonitoring and medication reconciliation interventions and their impact on the readmission rates, compliance of patients with the medications, and satisfaction to the patients (Shamali et al., 2025).

Phase II conducted quasi-experimental pre-post design in a mid-sized urban hospital. The data collected on 30 days HF readmission in terms of baseline in six months were compared to the results of interventions after the implementation of a more enhanced protocol of discharge. They represented the key interventions provided as early discharge planning during admission, individual education based on the teach-back method, discharge checklist, medication reconciliation, follow-up visit during a discharge, and a phone call placed by a nurse within 72 hours after the discharge. Outcomes measured included readmission rates, medication adherence (MMAS-8), patient satisfaction (HCAHPS), and emergency department visits.

Phase III revealed hypothetical findings showing a significant reduction in 30-day readmissions from 23% pre-intervention to 11% post-intervention (p = .001). High medication adherence improved from 28% to 54% (p < .001), patient satisfaction scores rose from 78 to 89 (p < .001), and HF-related emergency visits declined from 17% to 8% (p = .005). Logistic regression verified that post intervention participation and high medication adherence were effective predictors in a strong reduction of readmission risk (Williams, 2025).

In conclusion, this study show that nurse-led, structured discharge planning can provide a significant improvement in clinical and patient-centered outcomes of HF patients.

Nursing implications of this study encompass reaffirming the importance of transitional care education, incorporation of evidence-based discharge procedures in nursing educational standards, and the promotion of policies that allow coordination of nurse led care and minimize readmissions whilst maximizing the quality of care and health care expenses.

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” (Bradley et al. 2022). 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 is 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.

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 low socioeconomic patients are the worst offenders as a result of the inactive discharge planning besides the inability to avail post-discharge services. The interventions that helped to overcome these barriers (including transportation, medications, and telehealth based on the needs of patients) had the potential of eliminating the risks of readmission. 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 validate the significance of well-planned education that is accompanied by the help of nurses, the role of which is based on focusing on adhering to medications, monitoring symptoms, and follow-ups. It was established that another significant line of treatment to be applied and that can help to improve patient outcomes is multidisciplinary care teams involving discharge planners.

Fatani et al. (2025) examined the effect of discharge planning teams on the length of stay and readmission outcomes in neurological patients. Although the study is not HF specific, it presents an argument about whether principles of discharge as a diagnosis can be generalized or not. The reduced length of stay and readmission in general was also attributed to the existence of a special team, and that fact confirmed that the organizational component may contribute to the discharge outcomes greatly Wu et al. (2024).

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Research design and study methods

This 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” (Bradley et al. 2022). 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” (Rohde et al., 2023). 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

Results (Hypothetical)

This section presents the hypothetical findings of the quasi-experimental pre-post study designed to evaluate the effectiveness of an enhanced nurse-led discharge planning and patient education protocol for individuals hospitalized with heart failure (HF). The statistics presented in this paper will entail the projected results based on the trends of the literature and the impact of the designed transition care program. The outcomes are a descriptive statistic, primary and secondary outcomes, including statistics prepared thereon, and interpretation of findings. The limitations of the study are to be discussed, as well as the recommendations for future research.

Descriptive Statistics

The population of the research consisted of 400 adult patients, with the first 200 respondents constituting the pre-intervention cohort and the remaining 200 forming the post-intervention group. Inclusion criteria were satisfied by all the participants. These inclusion criteria consisted of a confirmed diagnosis of HF and discharge home or to self-care. There were no exclusion criteria, including transfer into long-term care or marked cognitive impairment without a caregiver.

The demographic characteristics of the population covered in the research showed that the mean age was approximately 70 years. The research participants ranged from 45 to 70 years, with the smallest number of people below 45 years. The gender of the respondents in both groups was nearly the same, with males making up over half of the respondents. The average of the racially and ethnically diverse group was White/African American, followed by Hispanic/Latino, and finally, other races. Most of the insurance was Medicare, then Medicaid; some were privately insured, and the remaining were uninsured.

Clinical characteristics of the pre- and post-interventional groups of the population were equalized. The New York Heart Association (NYHA) classification revealed that most patients were in Class II or III, with a smaller subset in Class IV, indicating advanced disease (Rohde et al., 2023). “The prevalence of comorbidities was similar across groups, with hypertension being the most common, followed by diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease (COPD)” (Rohde et al., 2023). Mean ejection fractions between the two groups had no significant difference, thus suggesting that both groups had similar levels of impairment of cardiac functions. These similarities show that overall, the sample did not differ in the background characteristics or clinical outcomes, so the likelihood of a confounding factor interfering with the results is lower.

Primary Outcomes

The primary outcome of the study was the 30-day readmission rate of hospitalization due to HF exacerbation (Gangu et al., 2022). In the initial sample of the group of patients at the beginning of the intervention, 23 percent represented cases of readmission rates in the initial month of discharge. In contrast, the post-intervention sample showed a low and conspicuous readmission rate of 11 percent. Statistical analysis using the Chi-square test confirmed that this reduction was statistically significant (p = .001).

Medication adherence, measured by the Morisky Medication Adherence Scale (MMAS-8), also showed considerable improvement following implementation of the intervention. At the pre-group level, 28 percent of the patients were assigned high adherence scores, and the remaining part belonged to medium and low adherence. The post-intervention group, in turn, achieved high adherence in 54 percent of the patients, whereas the percentage of patients with low adherence drastically reduced. The Chi-square test confirmed that these changes were statistically significant (p < .001).

Patient satisfaction, assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey focusing on discharge and care transition items, also improved (Bispott, 2024). The pre-intervention group's average score was 78, whereas the post-intervention group reached almost 89. Independent samples t-test analysis revealed that this increase in satisfaction was statistically significant (p < .001). These results indicate that the perception of patients subjected to the implemented intervention became better if the discharge process is considered more supportive, organized, and informative following the introduction of the intervention into practice.

Secondary Outcomes

Reduced effects of the intervention occurred in secondary outcomes. Emergency department (ED) visits for HF-related issues within 30 days of discharge decreased from 17 percent in the pre-intervention group to 8 percent in the post-intervention group, with statistical testing confirming the significance of this reduction (p = .005). This observation shows that not only was the step of hospital readmission reduced through improved discharge planning and education now, but also there was an opportunity to avoid crisis occasions, which might have required ED evaluation.

The length of stay (LOS) for the index hospitalization decreased modestly from an average of 5.8 days in the pre-intervention group to 5.2 days in the post-intervention group. While the difference did not reach statistical significance (p = .062), the trend aligns with prior research suggesting that effective discharge planning can contribute to more efficient care and earlier patient discharge without compromising safety.

Descriptive Analysis, Logistic Regression, and identification of S 30 30-day readmission. Group assignment emerged as a strong independent predictor, with patients in the post-intervention group demonstrating significantly lower odds of readmission compared to those in the pre-intervention group (odds ratio = 0.42, p = .001). High medication adherence was also associated with a lower risk of readmission (odds ratio = 0.38, p < .001). Conversely, having NYHA Class IV heart failure increased the likelihood of readmission (odds ratio = 2.14, p = .021). These outcomes prove the importance of the intervention and adherence behaviors in reducing readmission. Also, they emphasized the fact that the advanced HF patients remain at high risk even after the improvement in the discharge practices.

Interpretation of Hypothetical Findings

The research findings show that the nurse-led discharge planning and patient education intervention significantly improved clinical and patient-centered results (Amini, 2024). It is noteworthy that the 30-day readmission rate declined, especially as the indicator has been a long-established indicator of healthcare and the focus of the value-based payment initiatives in healthcare. The improvement in medication adherence suggests that it will be possible to schedule education interventions and carry them out in a way that empowers the patient to take control of their health.

The fact that the rates of satisfaction with the interventions increased significantly demonstrates that it is not only the medical component of it, but also the modality of compliance with the same tenets of the patient-centered concept. The patients reporting that they feel supported, informed, and prepared to engage in self-management once they leave the hospital have better chances of having smoother transitions and fewer complications, as well as feel more confident about their capability to manage HF on their own (Amini, 2024).

The further consequences of the research, i.e., the reduction of ED visits and the potential trend of reduced hospital stay duration, again support the cross-lingual positive influence of the holistic nature of the discharge planning. These advantages show that the intervention has potential economic benefits as well because it will likely lower the number of costs incurred due to unnecessary healthcare, since no unnecessary visits to the hospital are present, and the inpatient care remains efficient and optimized as well.

Research Limitations

The interpretation of such hypothetical results has several limitations that one should remember. The quasi-experimental design is a convenient trial to be conducted in the real-life scenario of a hospital; nevertheless, the design lacks randomization to eliminate selection bias. This limits the strength of causal inferences, since the findings may have relied on unobserved variables. Another aspect that will cast its shadow on the generalizability of the findings is the use of convenience sampling, as the sample may not be representative of a large population of HF patients in other hospitals or geographic regions.

Also, the research was based partially on self-reported measures of medication non-adherence and satisfaction, that is prone to social desirability bias and recall bias (Fahrni et al., 2022). The good acts or satisfaction may be overreported, particularly when probed by care personnel during patient release. The study was done in a single site, which implies that a variety of contextual factors peculiar to this hospital (including expertise of its staff, institutional culture, or the resources available) may have been among the contributing factors of the intervention's success.

Recommendations for Future Research

In future studies, it would also be important to consider the conduct of randomized controlled designs across various geographical locations of hospitals that would allow greater generalizability and internal legitimacy of findings to enhance the evidence base and address the identification gaps. In a bid to enhance the credibility of findings, the study population should become more representative in terms of demographic and socioeconomic groups of patients to determine whether the interventions are also equitable and effective for various patients.

A longer-term follow-up, such as after the discharge period of 30 days, would better explain the findings on whether the benefits of interventions are sustainable over more extended periods of health-related outcomes, such as 90-day readmissions, mortality rates, and health-related quality of life. Moreover, the interviews could also include cost-effectiveness analyses to enable healthcare organizations to estimate the financial consequences of adopting care units with similar nurse-led discharge planning procedures (Fahrni et al., 2022).

Lastly, specific studies of high-risk subgroups (i.e., patients with severe HF, patients with numerous comorbidities, or patients with low health literacy) may inform the creation of individualized interventions. Such possible examples might be higher telemonitoring, more frequent contact with patients during follow-ups, or cooperation with community health workers to address social determinants of health resulting in readmissions.

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. 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. The implications of the proposed quasi-experimental study, where it is presumed that the structured nurse-led discharge planning, which is considered part of the comprehensive patient education, can significantly reduce the number of hospital readmissions for heart failure patients within the first 30 days of readmission, are pretty profound. Moreover, it implies that the intervention positively impacts medication adherence and patient satisfaction and reduces the use of emergency services. Despite a few limitations inherent in the design and scope of the conducted research, these speculative findings are consistent with existing evidence, which determines the potentially crucial role of nursing in the development of safe and effective transitions of care. The paper has revealed the significance of transitional care as a pillar of good nursing, considering both clinical and patient-oriented outcomes. Utilizing similar steps in clinical practice, underpinning the identified restrictions, could help make the life of HF patients substantially easier and reduce the scope of readmission to the healthcare system

References

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