YISELL PHASE IV
PHASE III RESULTS
Student Name: Yisell Gonzalez
Institution: Florida National University
Course: Nursing Research & Evidence-Based Practice
Professor: Aciel Sagrera Mulen
February 9, 2026
Results Overview
The section presents the simulated results of a mixed-methods project that tested a structured transitional nursing intervention among the adults released with a heart failure (HF). The intervention involved standardized discharge instruction, medication reconciliation, scheduling of follow-ups, and nurse telephone call 48-72 hours of discharge. The quantitative outcomes have analyzed 30-day readmission, medication adherence, and follow-up attendance. The qualitative interviews involved the way the patients perceived quality change in the transition between the hospital and home. Results are given as per the design and tools as outlined in Phase II and are expected to give an idea of what findings would have appeared in a real implementation.
Description and Demographics of the Samples
The sample size was quantitative (n=120 adults), whose primary diagnosis was that of HF and had been discharged home by an acute care hospital. Sixty respondents were participating in the usual discharge care (control group), and 60 were participating in the structured transitional nursing intervention (intervention group). The average age of the participants was 67.4 years (SD = 9.2; 45-85 range). The sample consisted of 62 males (52 percent) and 58 females (48 percent). There was a distribution of ethnicity such that, Hispanic (46%), non-Hispanic White (32%), African American (18%), and others (4%). Most of the respondents (71%) had at least one other chronic condition (e.g., diabetes, hypertension). This comorbidity pattern is in line with the clinical complexity in transitional care literature of HF (Liu et al., 2023). The suitability of the group comparison was supported with baseline comparisons implying that the two groups were similar in terms of age, sex, ethnicity, and comorbidity burden.
Quantitative Findings
Thirty-Day Readmissions
The major outcome was 30-day readmission to the hospital. The readmission rate of 9 of 60 patients (15 Percent) in the intervention group was 30 days readmission rate. Twenty-eight percent of 60 patients (17 out of 60) were re-hospitalized in the control group.
A chi-square test showed that there was a statistically significant difference across groups, kh2(1, N = 120) = 4.01, p =.045. Practically, the intervention group had a reduced readmission rate, which indicated that a systematic transitional care program, led by nurses, can potentially decrease avoidable readmission rates. This direction of effect is compliant with the published analysis of the association of hospital-to-home transitional care programs within the HF populations (Feng et al., 2025).
Medication Adherence (MMAS-8)
The Morisky Medication Adherence Scale (MMAS-8) was the measurement of medication adherence. There was a higher mean score of adherence in the intervention group (M = 7.1, SD = 0.8) compared to the control group (M = 6.2, SD = 1.1). The difference was statistically significant, according to an independent samples t-test = t(118) = 5.12, p <.001.
These findings are in line with findings that patient- and family-centered transition interventions, in particular those that focus on discharge communication and follow-up, have the potential to enhance self-management behaviors following discharge (Chartrand et al., 2023).
Follow-Up Appointment Attendances
The attendance at follow-up appointments in 14 days after discharge was also studied. The follow up rate was simulated to be 82 percent of the intervention group and 61 percent of the control group.
One of the logistic regression models showed that the likelihood of attending the follow-up visit was significantly higher in those who participated in the transitional nursing intervention (OR = 2.9, 95% CI [1.3, 6.4], p =.008). This observation indicates that the intervention was not only useful in readmission outcomes, but also in enhancing the engagement in post-discharge care.
Qualitative Findings (Patient Interviews)
The participants who completed the semi-structured interviews were 15 participants out of the intervention group. The thematic analysis produced three themes:
The expectations are made clearer upon discharge
The participants explained that they had a stronger understanding of what to look at at home and when to seek assistance. They often remarked that discharge teaching was more specific and more readily applied to real-life activities.
Early nurse follow-up The 48-72-hour nurse call was highly valued by the patients. Some of them claimed that it was a type of safety check and they could be sure about medications or handle the symptoms at the first stage and the anxiety related to managing HF at home. It is stressed that such continuity is one of the distinguishing characteristics of transitional care in HF (Liu et al., 2023).
Perceived co-ordination and respect
The respondents expressed greater satisfaction when they believed that the care team is on track and communication is effective. Patients associated this coordination with reduced number of missed steps (e.g. being aware of the date/time of the follow-up appointments and being aware of medication changes).
Process Results: Algorithm Adherence
To assist in delivering consistency, the flow process was structured (discharge readiness checklist - medication reconciliation - education bundle - follow-up scheduling - post-discharge call). Implementation fidelity rate in simulated program monitoring was over 90 per cent, which means that the workflow was viable in a normal nursing practice. High adherence implies that standardized transitional care steps may decrease the variability in discharge practices and help to achieve reliability in care transitions (Feng et al., 2025).
Limitations
A number of limitations are to be mentioned. To begin with, the results indicate a simulation analysis as opposed to actual implementation, therefore, the results cannot be discussed as clinical evidence. Second, the quantitative part is based on a convenience sample of one setting, which could be a limitation to generalization. Third, medical adherence was self-reported which can exaggerate adherence because of recall bias or social desirability bias.
Lastly, the HF patients usually have other chronic conditions, so unmeasured variables (e.g., social support, health literacy, transportation access, etc.) may affect readmission and follow-up outcomes. These variables should be incorporated in future studies to explain which patients are most beneficial to the transitional nursing interventions.
Future Study Recommendations
This intervention needs to be tested in a multi-site design in the future with either randomization to minimize the selection bias. Follow-up was only up to 30 days, which did not permit the measurement of the longer-term effects such as repeat readmissions and quality-of-life measures. The comparison of patient education methods based on the level of literacy and language choice could also be used to enhance the findings, particularly in multicultural groups. Lastly, the cost-related outcomes should be investigated, as transitional care programs are frequently considered on the basis of the fact that they may decrease preventable utilization (Chartrand et al., 2023).
Conclusion
The simulated results indicate that systematic transitional nursing interventions of patients with HF can decrease 30-day readmissions and enhance medication adherence and attendance of follow-ups. According to the results of the interview, patients also appreciate clear discharge teaching and initial contact with nurses as signs of continuity and support. Collectively, these findings support the core of transitional nursing as an enhancement in terms of safety and outcome during the hospital-to-home transition of HF patients.
References
Chartrand, J., Shea, B., Hutton, B., Dingwall, O., Kakkar, A., Chartrand, M., Poulin, A., & Backman, C. (2023). Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs. International Journal for Quality in Health Care, 35(4). https://doi.org/10.1093/intqhc/mzad102
Feng, Z.-F., Liu, Y., Salvador, J. T., Bravo, M., Ann, M., Huang, X.-Y., Zhang, L., & Liu, S. (2025). Implementation and evaluation of hospital-to-home transitional care intervention in patients with chronic heart failure. BMC Nursing, 24(1). https://doi.org/10.1186/s12912-025-03447-5
Liu, S., Xiong, X., Chen, H., Liu, M. L., Wang, Y., Yang, Y., Zhang, M., & Xiang, Q. (2023). Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers’ Evolutionary Approach. Risk Management and Healthcare Policy, 16, 2063–2076. https://doi.org/10.2147/rmhp.s427495