YISEL PP

Improving Transitional Care for Heart Failure Patients

Phase IV Assignment

Student name: Yisell Gonzalez

Institution : Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: February 16, 2026

Abstract

The issue of readmission among heart failure (HF) patients remains old in healthcare systems all over the world and in most of the cases, they are occasioned by the lack of continuity in the processes of transitional care. The frequencies of HF patients readmission in 30 days of discharge are nearly 25 percent of patients which is why the structured and evidence-based nursing interventions are important. The contributing factors to preventable readmissions in phase I of this project were identified to be the gaps in the discharge education, medication reconciliation and post-discharge coordination. The endeavor fitted in the primary AACN Master Essentials, i.e., Essential I (Liberal Education of Advanced Practice), Essential II (System Leadership), Essential III (Clinical Scholarship and Evidence-Based Practice), Essential VI (Interprofessional Collaboration) and Essential VII (Population Health).

Phase II was a mixed-methods trial which involved the evaluation of a structured transitional nursing intervention which entailed standardized discharge teaching, medication reconciliation, follow up appointment scheduling and a 48-72-hour of nurse-led telephone follow-up. The 30-day readmission rates, medication adherence using the Morisky Medication Adherence Scale, and attendance of follow-up appointment were measured quantitatively. Patient perceptions of continuity of care were investigated in qualitative interviews.

Phase III featured simulated results of the reduced intervention rate of 30-day readmission compared to usual care, the rise in medication adherence scores, and the response of compliance with follow-up. Thematic analysis of the qualitative data revealed the themes of improved self-confidence, continuity of care, and increased satisfaction with nursing support.

The limitations are one-site sampling, the use of self-reported measures of adherence, and the hypothetical nature of the analysis. Multi-site randomized studies, extended follow-up, and cost-effectiveness studies should be used in future studies. The implication to nursing practice is reviewing discharge protocols, standardizing nurse-led discharge follow-up procedures, and enhancing transitional care competencies in graduate nursing education. The structured transitional nursing programs can benefit patient safety, decrease healthcare use and outcomes of HF populations.

Introduction

In healthcare, readmission of patients with heart failure (HF) to the hospital has been one of the most burning concerns across the entire world's healthcare systems. The issue of transitional care, or healthcare transfer between two healthcare settings, has been selected as one of the primary factors in reducing the number of adverse effects, including medication errors, ineffective treatment plan compliance, and unnecessary hospital readmission (Al-Tamimi et al., 2021). The gaps, which exist in the field of transitional care, should be perceived and applied to improve the overall nursing care quality and safety of patients.

Problem

Patients with heart failure have high readmission rates because nearly a quarter of the total number of patients are readmitted to the hospital within 30 days of discharge (Foroutan et al., 2023). This is the primary weakness in the practices of transitional care. Its reasons include the inappropriate education of patients on how to self-manage, a lack of agreement between the hospital workers and the community professionals, and, finally, a lack of coordination of the post-discharge treatment. These gaps are bound to cause adverse effects, including medication errors, escalation of the condition, and unnecessary readmission. Lack of standardized transitional care guidelines in all health facilities can only attest to the fact that research should be undertaken, which will evaluate evidence-based interventions that the nursing staff members can implement as a means of addressing the gap in care and continuity in patients with chronic conditions such as HF.

Implications of the Problem to Nursing

Transitional nursing is essential to improve patient outcomes in times of care transitions when patients are at a vulnerable time. The nurses will be involved in informing the patients, following up on their appointments, evaluating the domestic surroundings, and the mechanism through which the hospital and the community providers communicate (Tyler et al., 2023). By providing continuity of care, nurses will be able to reduce the rate of hospital readmission, improve adherence to the treatment plan, and enhance patient satisfaction. Nursing is also interested in the field of practice as being directly impactful on patient safety and aligning with the principles of patient-centered care. The solution of the transitional care issue also contributes to the achievement of the overall goals of the healthcare reform to improve the health outcomes of the population and reduce the number of healthcare expenditures associated with preventable readmissions. Good transitional nursing intervention is beneficial not only to improve the performance of individual patients but also the performance of the health care systems as well.

Purpose of the Research

This research is expected to investigate the effectiveness of structured transitional nursing programs in preventing hospital admissions in patients with heart failure in the 30-day period. This paper will analyze some of the interventions that include discharge education programs, post-discharge telephone follow-ups, and the use of primary care and community resources. The ultimate goal is to determine evidence-based practices that could be adopted in nursing attention toward increasing patient outcomes, diminishing readmissions, and also boosting the quality of transitional care. The proposed study will inform about evidence-based practices that can be applied in different healthcare environments by emphasizing the nursing role in the context of transitional care to guarantee that HF patients receive safer and more effective transitions.

Research Questions

“What is the effectiveness of structured transitional nursing interventions in heart failure patients about reducing 30-day readmission of heart failure patients?” (Tyler et al., 2023)

What are the most effective transitional practices that will result in patient compliance with the discharge orders?

What are the perceptions of patients on the quality of transitional services and their effectiveness by nurses?

Master’s Essentials that Align with the Topic

This study is consistent with some of the AACN Master slide essentials in advancing nursing practice:

 Essential I: Liberal Education to Nursing Advanced Practice - It provides insight into the knowledge of the methods of studying the healthcare system, population health, and patient-centered care methods (Mackavey et al., 2025).

Essential II: Organization and Systems Leadership to develop harmonized and evidence-based interventions that can improve health services transition in health care systems.

Essential III: Clinical Scholarship, Analysis, and Evidence-Based Practice, and analytical approach.

Essential VI: Interprofessional Cooperation to Enhance Patient Health Outcomes

Essential VII: Population Health and Clinical Prevention to Improve Health - focuses on health prevention and promotion of health against readmissions and safety in patients.

Conclusion

In summation, planned transition nursing programs will increase treatment regimens compliance, decrease readmission, and improve patient satisfaction. By implementing such interventions and studies, this research will provide evidence-based recommendations that will be used to guide the nurses towards the adoption of the best practices in transitional care.

Brief Literature Review

Readmissions during hospitalization are high rates among patients with heart failure (HF), as it has been a significant issue for the healthcare systems worldwide. Approximately 20-25 percent of HF patients experience readmission within 30 days of discharge, which is typically associated with a fragmented transition process (Chartrand et al., 2023). Transitional care involves a complex set of actions within a restricted timeframe, with the purpose of providing continuity and coordination of patient transitions across medical facilities, including hospital-to-home. Low-quality transitional care is the reason behind medication inconsistencies, low ability to manage symptoms, lack of follow-up, and misunderstanding about self-care roles by the patient (Xie et al., 2022).

According to Feng et al. (2025), structured transitional nursing interventions can be very successful as a way to counter these risks. Patient-centered education based on discharge education has been identified to positively impact patient self-management behaviors and medication and nutritional adherence (Chartrand et al., 2023). Discharge planning, primarily managed by nurses, including personalized education, written instructions, and outlining follow-up plans, has an enormous impact on preventable readmissions. Besides, shared communication between community-based clinicians and hospital providers is also defined as one of the key aspects of effective transitions, which would reduce the rate of loss of information when changing care (Li et al., 2024).

Li et al. (2024) in their study found that post-discharge follow-up interventions also enhance the transitional care outcomes. Follow-ups by registered nurses through telephone within 48-72 hours of discharge help identify symptom exacerbation, medication problems, and unsatisfied social needs as early as possible. Randomized controlled trials suggest that these follow-ups can minimize emergency department visits and readmissions of HF patients in hospitals.

Furthermore, Liu et al. (2023) in their study found that transitional care models that combine nursing, primary care, or community resource utilization are better in-patient satisfaction and quality-of-life outcomes, as shown to be multidisciplinary. The literature, in general, highlights the point that nurse-led transitional care initiatives are evidence-based strategies to lower the number of HF readmissions and enhance patient safety.

Methodology and design of the study

The research design of the proposed study will be a mixed-method research design with the aim of thoroughly assessing the effectiveness of structured transitional nursing interventions to reduce 30-day readmission rates among HF patients. The quantitative part will use a quasi-experimental design where the results of the patients who have undergone regular discharge care and those who have undergone a structured transitional nursing program will be compared. During this program, standardized discharge education, medication reconciliation, some follow-up appointments, and post-discharge telephone assistance will be involved.

For quantitative data, the data will be collected in the form of a retrospective review of electronic health records (EHRs) to offer baseline data, whereas prospective data will be collected after the implementation of the intervention. For qualitative data, semi-structured interviews will be conducted on the selected participants receiving the intervention and will give insight into the perceived effectiveness, the clarity of discharge instructions, and the effects of nursing support on the transition process. Quantitative findings and qualitative experiences will help to have a more detailed impression of both the quantifiable effectiveness and patient-centered attitudes, which, in turn, are in line with the principles of the evidence-based nursing practice (Liu et al., 2023).

Sampling Methodology

A mixed sampling method will be applied in this study. In the case of the quantitative component, a convenience sample of adult patients with a heart failure diagnosis and discharged from an acute care hospital will be used. The inclusion criteria will consist of a confirmed diagnosis of HF, age 18 years and older, and home discharge. All the patients will be excluded as they will be sent to long-term care or hospice care facilities to limit confounding factors.

In the qualitative part, purposive sampling will be used to identify the people in the intervention group who will be interested in discussing their experiences. This will mean that the participants will be in direct exposure to the structured transitional nursing interventions under study. The power analysis will be used to determine the sample size to be used in the quantitative component in order to achieve a satisfactory level of statistical significance, and qualitative sampling will be done until a state of data saturation is reached.

Necessary Tools

There are several data collection instruments that will be required in this work. The EHR will offer the quantitative data in the form of readmission rates, demographics, and clinical indicators. The medication adherence will be addressed with the help of the self-report measures, such as the Morisky Medication Adherence Scale, which was validated. The adherence to following the appointment will be screened with the follow-up clinic attendance records.

In the case of the qualitative element, a semi-structured interview guide is going to be designed relying on the frameworks of transitional care and available literature (Liu et al., 2023). The interviews will be audio-taped and transcribed word-for-word to be analyzed thematically. Moreover, there will be standardized discharge education checklists and telephone follow-up scripts as means of intervention to be consistent for all participants.

Algorithms and Flow Maps

A transitional care flow map detailing the nursing activities, including admission until 30 days even after discharge, will be created to support the implementation of standardization. The algorithm will consist of some of the most important steps, i.e., patient identification, discharge readiness assessment, delivery of education, medication reconciliation, follow-up appointment scheduling, and post-discharge telephone calls. Process visual mapping leads to greater consistency, less variability in practice, and implementation of evidence-based guidelines (Taylor et al., 2025). These tools are important in the translation of research discoveries to an improvement of sustainable nursing practice.

Conclusion

In summation, this essay shows that low-quality transitional care is the reason behind medication inconsistencies, low ability to manage symptoms, lack of follow-up, and misunderstanding about self-care roles by the patient. Therefore, transitional care helps in addressing the issue of readmissions during hospitalization. Transitional care involves a complex set of actions within a restricted timeframe with the aim of providing patient’s transition and coordination across medical facilities, including hospital-to-home. Structured transitional nursing interventions are a viable solution to the high-patient readmission rates in heart failure patients. This literature review shows that patient and family-centered education, proper discharge planning, and active post-discharge follow-up helps in reducing care fragmentation and ensuring continuity across environments.

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

Al-Tamimi, M. A.-A., Gillani, S. W., Abd Alhakam, M. E., & Sam, K. G. (2021). Factors Associated With Hospital Readmission of Heart Failure Patients. Frontiers in Pharmacology, 12(12). https://doi.org/10.3389/fphar.2021.732760

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

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Li, W., Shi, S., Shi, Y., Feng, X., Li, Y., Guo, Y., Xu, J., Cui, L., & Wang, M. (2024). Exploring Stakeholder Perspectives on the Transitional Care Needs of Elderly Patients from Hospital to Home: A Phenomenological Study in Shanxi Province, China.  Journal of Multidisciplinary Healthcare,  Volume 17, 5457–5471. https://doi.org/10.2147/jmdh.s484187

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

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