Date of Award
2025
Document Type
Doctor of Nursing Practice (DNP)
Degree Name
Doctor of Nursing Practice (DNP)
Department
Nursing
Committee Chair
Tracy Lakin, Charles Reynolds
Subject(s)
Heart failure--Treatment, Nursing care plans, Continuum of care
Abstract
Heart failure is a global issue affecting millions of people. Readmissions to the hospital for heart failure are common. Many patients are readmitted for their heart failure within 30 days of discharge. The 30-day readmission rate for patients with heart failure at Dekalb Regional Medical Center in Fort Payne, Alabama, is close to the Centers for Medicare and Medicaid’s penalty rate. Currently, there is no standardized process for transitioning hospitalized patients with heart failure to home. Implementing a nurse-led transitional care protocol for patients with heart failure is a proven method to reduce 30-day readmission rates. Transitional care protocols require a multidisciplinary team, including the provider, pharmacist, and nurse navigator. A transitional care protocol was implemented in both an intensive care and medical-surgical unit to decrease readmission rates for patients with heart failure. The evidence-based protocol included in-hospital heart failure-specific education, accurate and personalized medication reconciliation, timely post-discharge follow-up appointments, and discharge follow-up phone calls. After a 12-week implementation, analysis was performed to assess how many patients were able to have a follow-up appointment within the recommended time and how many were readmitted to the hospital. Forty-four patients were invited to participate in the protocol. A total of 24 patients completed the protocol in its entirety, including follow-up appointments. Out of the 24 patients, two patients were readmitted to the hospital. This equated to a readmission rate of 8.3%. This project showed that a nurse navigator-led transitional care protocol is effective in reducing readmission rates for patients with heart failure at Dekalb Regional Medical Center.
Recommended Citation
Ortega, Kathryn, "Reducing 30-day readmission rates for patients with heart failure through the utilization of a nurse-led transitional care protocol at a rural hospital" (2025). Doctor of Nursing Practice (DNP). 147.
https://louis.uah.edu/uah-dnp/147