The students will continue the research topic already started. In this paper you are going to conduct a brief literature review on your topic. This paper mus

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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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