Author

Gerald Ubaka

Date of Award

2024

Document Type

Doctor of Nursing Practice (DNP)

Degree Name

Doctor of Nursing Practice (DNP)

Department

Nursing

Committee Chair

Susan Alexander

Subject(s)

Congestive heart failure--Nursing, Patient monitoring

Abstract

Congestive heart failure (CHF) is one of the leading ambulatory care sensitive conditions (ACSC) that lead to unplanned readmissions in the United States and among veterans of the Atlanta Veterans Healthcare System (AVAHCS). Patients who are diagnosed with CHF can incur medical and financial difficulties that have substantial negative impacts on their health outcomes and quality of life. This project implemented a checklist for the weekly monitoring of the care of veterans who have been hospitalized for CHF exacerbations in the last 12 months, and who have a 50% or higher 3-month probability (3M) risk of unplanned readmission. This nurse-based monitoring care process puts the registered nurse (RN) care manager in the center of the care of the veteran. A repeated measures test was used to analyze the pre- and post- implementation data, to determine statistical significance of the implemented variable. The pre- and post - data analyzed include, 1) Preadmission date/frequency, and 2) 3M score pre and post.

Available for download on Thursday, November 06, 2025

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