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assigment phase 1 and Correct Phase 1 for the professor'feedback
2 years ago 30
NursingResearchandEvidencepaper2.docx
Phase1-Planning.edited1.pdf
NursingResearchandEvidencepaper2.docx
Nursing Research and Evidence-Based Practice-DBX-DL02 Carmen Lazo
Phase II Research Paper
Top of Form
Bottom of Form
Exercise Content
1.
Top of Form
Phase II- 11/23/24 by 11:59pm
Library Assignment is required.
Library Assignment: This phase of your project will require everyone to visit the University Library or online to obtain information related to their project.
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 must include at least 5 supporting articles related to the chosen topic (3 are peer-review journal articles) and will provide the desired methodology for their project. The paper will be minimum five to six pages (strict adherence to APA guidelines is required). Additionally, is it important the quality of the writing, not the quantity. The writings should be concise, factual and disseminates information. It should not be your opinion. Use the following as subheadings for your paper.
The paper will include:
1. Brief literature review- Support your topic
2. Methodology and design of the study (Be detailed )
3. Sampling methodology- Qualitative or Quantitative or Mixed method for example
4. Necessary tools- will you be using any surveys?
5. Any algorithms or flow maps created- (illustrations)
This will be considered a Library Assignment as you will need to visit the library to obtain information
Bottom of Form
Phase1-Planning.edited1.pdf
1
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days
Among Patients with Chronic Heart Failure
Antonio Estremera
FNU
Nursing Research and Evidence-Based Practice
Professor: Dr. Carmen Lazo
November 9, 2024
2
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days
Among Patients with Chronic Heart Failure
Chronic diseases are among the leading causes of hospitalization, death, and economic
burden globally. Chronic diseases cause 73% of all deaths and 60% of the global disease burden,
respectively. One of the major problems in chronic disease management is the frequent
readmission of patients to hospitals; this is partly because transitional care is very fragmented.
More than 50% of patients with chronic diseases are readmitted to hospitals within 30 days
following discharge (Joo & Liu, 2021). Heart failure is among the major chronic diseases. It is a
prevalent condition affecting more than 6.7 million people aged 20 years and above in the United
States (CDC, 2024). Transitional care of patients with chronic conditions such as CHF is an
important element in health care, as it appraises continuity and safety as the patients undergo
different transitions from one care setting to another. Given the above figures, transitional care
interventions are crucial in reducing readmission rates to improve patient outcomes and decrease
overall healthcare system burdens. This paper discusses transitional care's role in managing CHF
patients post-discharge to minimize early hospital readmissions, drawing on prior nursing
research to emphasize its importance.
Identification of the Problem
Hospital readmission in the first 30 days after being discharged is a recurring problem in
healthcare, especially with patients diagnosed with chronic heart failure. These readmissions
may indicate potential gaps in discharge planning, patient education, and support in the post-
discharge periods, which are integral to transitional care (Ayenew et al., 2023). The majority of
patients with CHF are not engaged in illness self-management because of complex medical
regimens, diet restrictions or continuous monitoring. According to Becker et al. (2021), these
3
readmissions for admission happen due to failure in communication, follow-up services, and
support of such patients any time they go to their homes from the hospital. This issue is linked to
patient morbidity and mortality and healthcare system expenditures. Managing these factors may
improve post-discharge transitional care measures to improve patient stability and reduce
readmission rates in these populations (Rammohan et al., 2023).
Significance of the Problem to Nursing
This issue of readmission among CHF patients is highly significant in the nursing field,
especially in transitional and community-based settings. Nurses are central in discharge
planning, patient education, and coordinating care to support the patient through the transitional
period. Continuation of care is one of the major responsibilities of nursing professionals,
something quite relevant to these patients, who require detailed guidance in managing their
condition successfully at home (Karam et al., 2021). Nurses can help promote improved
compliance with treatment regimens, reduced medication errors, and increased patient-family
empowerment to engage in self-care through implementing and refining transitional care
strategies. The roles promote patient outcomes and support healthcare goals of quality of life and
preventable hospital readmissions. Transitional care, therefore, allows nurses to apply advanced
skills in the coordination of care, patient advocacy, and working collaboratively with other
professionals from other disciplines.
Purpose of the Research
This study aims to identify gaps in the current transitional care interventions and compare
the 30-day readmission rate for patients with chronic heart failure. This research will further
refine the understanding of which aspects of transitional care, including follow-up visits, patient
education, and home health monitoring, are the most valuable for avoiding early readmissions.
4
The research also aims to investigate how tailored transitional care plans can be adapted to meet
patients' individual needs, recognizing that CHF patients vary in severity, comorbid conditions,
and social support. The ultimate goal of this study is to provide evidence-based
recommendations for healthcare providers, particularly nurses, on best practices for managing
CHF patients post-discharge to improve outcomes and reduce readmissions.
Research Questions
1. What specific components of transitional care are most effective in reducing 30-day
readmission rates for patients with chronic heart failure?
2. How does patient education and self-management support during the transition period
impact readmission rates in this population?
3. How can individualized care plans enhance the effectiveness of transitional care for
patients with CHF?
4. What role do follow-up interventions, such as home visits or telehealth, play in
supporting CHF patients post-discharge?
Master's Essentials Aligned with the Topic
Essential I: Background for Practice from Sciences and Humanities
This essential underscores the need for nursing practice based on a wide knowledge of
sciences and humanities. During the care of patients with CHF, nurses will draw knowledge from
physiology, pharmacology, and patient psychology to develop comprehensive transitional care
plans addressing both physical and mental health. By integrating these multifaceted arenas of
cognition, nurses will be better equipped to develop holistic and personalized plans of care that
meet the complex needs of CHF patients during their transition from hospital to home.
Essential II: Organizational and Systems Leadership
5
This essential highlights the need for a higher level of professional nursing leadership
competencies to maneuver and coordinate healthcare systems environment solutions efficiently.
In particular, when discharging CHF patients, nurses need to involve other departments, support
the need for resources, and invest in structured transition plans to provide the appropriate care
continuity. Strong organizational and systems leadership allows nurses to reduce readmissions
through systemic improvements, demonstrating its impact on patient outcomes.
Essential III: Quality Improvement and Safety
This essential emphasizes utilizing improvement and quality management concepts to
boost the efficiency of patient safety as well as treatment. Nurses who work with CHF patients
diagnose the factors that cause readmission and implement knowledge-based changes in the
transitional care processes of the patients. Nurses play an important role in making discharge
plans safer and less risky, meaning they try to reduce the factors that can lead to readmission of
heart failure patients by paying a lot of attention to the safety of patients any time they are being
discharged or followed up.
Essential IV: Translating and Integrating Scholarship into Practice
This essential emphasizes the need for applied research conducted to enhance patient care
through the new implementation of practical nursing practices (Giddens et al., 2022).
Transitional care and readmission control are evidence-based practices. Hospital nurses use
research to handle CHF patients and apply effective solutions. They ensure the research findings
are implemented within practice, promoting patient care, especially for the most vulnerable.
Essential VII: Interprofessional Collaboration for Improving Patient and Population
Health Outcomes
6
This essential stresses the need to collaborate with an interactive and multifaceted team in
planning and providing client care that enhances pen-patient status. Transitional care for CHF
patients generally requires teamwork between nurses, physicians, pharmacists, social workers,
and home health aides to provide all health needs. This collaboration guarantees that CHF
patients get holistic and comprehensive care at each stage of their cycle, hence minimizing NICU
readmission rates.
Essential VIII: Clinical Prevention and Population Health for Improving Health
This essential calls for integrating preventive care and population health, increasing well-
being, and decreasing the number of disease incidents (Giddens et al., 2022). Transitional care
for CHF patients relates to and supports this goal by addressing the condition and averting
readmission by following up and educating patients on the necessary care. Nurses can use the
interventions to enhance the well-being of CHF patients and contribute to healthcare policies that
reduce the demands on health facilities.
7
References
Ayenew, B., Kumar, P., Hussein, A. A., Gashaw, Y., Girma, M., Ayalew, A., & Tadesse, B.
(2023). Heart failure drug classes and 30-day unplanned hospital readmission among
patients with heart failure in Ethiopia. Journal of Pharmaceutical Health Care and
Sciences, 9(1). https://doi.org/10.1186/s40780-023-00320-y
Becker, C., Zumbrunn, S., Beck, K., Vincent, A., Loretz, N., Müller, J., Amacher, S. A.,
Schaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at
Hospital Discharge and Rates of Readmission. JAMA Network Open, 4(8).
https://doi.org/10.1001/jamanetworkopen.2021.19346
CDC. (2024). Cardiovascular diseases (CVDs). Who. int. https://www.who.int/news-room/fact-
sheets/detail/cardiovascular-diseases
Giddens, J., Douglas, J. P., & Conroy, S. (2022). The Revised AACN Essentials: implications for
nursing regulation. Journal of Nursing Regulation, 12(4), 16–22.
https://doi.org/10.1016/s2155-8256(22)00009-6
Joo , J. Y., & Liu , M. F. (2021). Effectiveness of transitional care interventions for chronic
illnesses: A systematic review of reviews. Applied Nursing Research, 61, 151485.
https://doi.org/10.1016/j.apnr.2021.151485
Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon,
C. (2021). Nursing care coordination for patients with complex needs in primary
healthcare: a scoping review. International Journal of Integrated Care, 21(1), 16.
https://doi.org/10.5334/ijic.5518
Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S.,
Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing
8
care transition teams to mitigate hospital readmissions and improve patient outcomes.
Cureus, 15(5). https://doi.org/10.7759/cureus.39022
NursingResearchandEvidencepaper2.docx
Nursing Research and Evidence-Based Practice-DBX-DL02 Carmen Lazo
Phase II Research Paper
Top of Form
Bottom of Form
Exercise Content
1.
Top of Form
Phase II- 11/23/24 by 11:59pm
Library Assignment is required.
Library Assignment: This phase of your project will require everyone to visit the University Library or online to obtain information related to their project.
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 must include at least 5 supporting articles related to the chosen topic (3 are peer-review journal articles) and will provide the desired methodology for their project. The paper will be minimum five to six pages (strict adherence to APA guidelines is required). Additionally, is it important the quality of the writing, not the quantity. The writings should be concise, factual and disseminates information. It should not be your opinion. Use the following as subheadings for your paper.
The paper will include:
1. Brief literature review- Support your topic
2. Methodology and design of the study (Be detailed )
3. Sampling methodology- Qualitative or Quantitative or Mixed method for example
4. Necessary tools- will you be using any surveys?
5. Any algorithms or flow maps created- (illustrations)
This will be considered a Library Assignment as you will need to visit the library to obtain information
Bottom of Form
Phase1-Planning.edited1.pdf
1
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days
Among Patients with Chronic Heart Failure
Antonio Estremera
FNU
Nursing Research and Evidence-Based Practice
Professor: Dr. Carmen Lazo
November 9, 2024
2
Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days
Among Patients with Chronic Heart Failure
Chronic diseases are among the leading causes of hospitalization, death, and economic
burden globally. Chronic diseases cause 73% of all deaths and 60% of the global disease burden,
respectively. One of the major problems in chronic disease management is the frequent
readmission of patients to hospitals; this is partly because transitional care is very fragmented.
More than 50% of patients with chronic diseases are readmitted to hospitals within 30 days
following discharge (Joo & Liu, 2021). Heart failure is among the major chronic diseases. It is a
prevalent condition affecting more than 6.7 million people aged 20 years and above in the United
States (CDC, 2024). Transitional care of patients with chronic conditions such as CHF is an
important element in health care, as it appraises continuity and safety as the patients undergo
different transitions from one care setting to another. Given the above figures, transitional care
interventions are crucial in reducing readmission rates to improve patient outcomes and decrease
overall healthcare system burdens. This paper discusses transitional care's role in managing CHF
patients post-discharge to minimize early hospital readmissions, drawing on prior nursing
research to emphasize its importance.
Identification of the Problem
Hospital readmission in the first 30 days after being discharged is a recurring problem in
healthcare, especially with patients diagnosed with chronic heart failure. These readmissions
may indicate potential gaps in discharge planning, patient education, and support in the post-
discharge periods, which are integral to transitional care (Ayenew et al., 2023). The majority of
patients with CHF are not engaged in illness self-management because of complex medical
regimens, diet restrictions or continuous monitoring. According to Becker et al. (2021), these
3
readmissions for admission happen due to failure in communication, follow-up services, and
support of such patients any time they go to their homes from the hospital. This issue is linked to
patient morbidity and mortality and healthcare system expenditures. Managing these factors may
improve post-discharge transitional care measures to improve patient stability and reduce
readmission rates in these populations (Rammohan et al., 2023).
Significance of the Problem to Nursing
This issue of readmission among CHF patients is highly significant in the nursing field,
especially in transitional and community-based settings. Nurses are central in discharge
planning, patient education, and coordinating care to support the patient through the transitional
period. Continuation of care is one of the major responsibilities of nursing professionals,
something quite relevant to these patients, who require detailed guidance in managing their
condition successfully at home (Karam et al., 2021). Nurses can help promote improved
compliance with treatment regimens, reduced medication errors, and increased patient-family
empowerment to engage in self-care through implementing and refining transitional care
strategies. The roles promote patient outcomes and support healthcare goals of quality of life and
preventable hospital readmissions. Transitional care, therefore, allows nurses to apply advanced
skills in the coordination of care, patient advocacy, and working collaboratively with other
professionals from other disciplines.
Purpose of the Research
This study aims to identify gaps in the current transitional care interventions and compare
the 30-day readmission rate for patients with chronic heart failure. This research will further
refine the understanding of which aspects of transitional care, including follow-up visits, patient
education, and home health monitoring, are the most valuable for avoiding early readmissions.
4
The research also aims to investigate how tailored transitional care plans can be adapted to meet
patients' individual needs, recognizing that CHF patients vary in severity, comorbid conditions,
and social support. The ultimate goal of this study is to provide evidence-based
recommendations for healthcare providers, particularly nurses, on best practices for managing
CHF patients post-discharge to improve outcomes and reduce readmissions.
Research Questions
1. What specific components of transitional care are most effective in reducing 30-day
readmission rates for patients with chronic heart failure?
2. How does patient education and self-management support during the transition period
impact readmission rates in this population?
3. How can individualized care plans enhance the effectiveness of transitional care for
patients with CHF?
4. What role do follow-up interventions, such as home visits or telehealth, play in
supporting CHF patients post-discharge?
Master's Essentials Aligned with the Topic
Essential I: Background for Practice from Sciences and Humanities
This essential underscores the need for nursing practice based on a wide knowledge of
sciences and humanities. During the care of patients with CHF, nurses will draw knowledge from
physiology, pharmacology, and patient psychology to develop comprehensive transitional care
plans addressing both physical and mental health. By integrating these multifaceted arenas of
cognition, nurses will be better equipped to develop holistic and personalized plans of care that
meet the complex needs of CHF patients during their transition from hospital to home.
Essential II: Organizational and Systems Leadership
5
This essential highlights the need for a higher level of professional nursing leadership
competencies to maneuver and coordinate healthcare systems environment solutions efficiently.
In particular, when discharging CHF patients, nurses need to involve other departments, support
the need for resources, and invest in structured transition plans to provide the appropriate care
continuity. Strong organizational and systems leadership allows nurses to reduce readmissions
through systemic improvements, demonstrating its impact on patient outcomes.
Essential III: Quality Improvement and Safety
This essential emphasizes utilizing improvement and quality management concepts to
boost the efficiency of patient safety as well as treatment. Nurses who work with CHF patients
diagnose the factors that cause readmission and implement knowledge-based changes in the
transitional care processes of the patients. Nurses play an important role in making discharge
plans safer and less risky, meaning they try to reduce the factors that can lead to readmission of
heart failure patients by paying a lot of attention to the safety of patients any time they are being
discharged or followed up.
Essential IV: Translating and Integrating Scholarship into Practice
This essential emphasizes the need for applied research conducted to enhance patient care
through the new implementation of practical nursing practices (Giddens et al., 2022).
Transitional care and readmission control are evidence-based practices. Hospital nurses use
research to handle CHF patients and apply effective solutions. They ensure the research findings
are implemented within practice, promoting patient care, especially for the most vulnerable.
Essential VII: Interprofessional Collaboration for Improving Patient and Population
Health Outcomes
6
This essential stresses the need to collaborate with an interactive and multifaceted team in
planning and providing client care that enhances pen-patient status. Transitional care for CHF
patients generally requires teamwork between nurses, physicians, pharmacists, social workers,
and home health aides to provide all health needs. This collaboration guarantees that CHF
patients get holistic and comprehensive care at each stage of their cycle, hence minimizing NICU
readmission rates.
Essential VIII: Clinical Prevention and Population Health for Improving Health
This essential calls for integrating preventive care and population health, increasing well-
being, and decreasing the number of disease incidents (Giddens et al., 2022). Transitional care
for CHF patients relates to and supports this goal by addressing the condition and averting
readmission by following up and educating patients on the necessary care. Nurses can use the
interventions to enhance the well-being of CHF patients and contribute to healthcare policies that
reduce the demands on health facilities.
7
References
Ayenew, B., Kumar, P., Hussein, A. A., Gashaw, Y., Girma, M., Ayalew, A., & Tadesse, B.
(2023). Heart failure drug classes and 30-day unplanned hospital readmission among
patients with heart failure in Ethiopia. Journal of Pharmaceutical Health Care and
Sciences, 9(1). https://doi.org/10.1186/s40780-023-00320-y
Becker, C., Zumbrunn, S., Beck, K., Vincent, A., Loretz, N., Müller, J., Amacher, S. A.,
Schaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at
Hospital Discharge and Rates of Readmission. JAMA Network Open, 4(8).
https://doi.org/10.1001/jamanetworkopen.2021.19346
CDC. (2024). Cardiovascular diseases (CVDs). Who. int. https://www.who.int/news-room/fact-
sheets/detail/cardiovascular-diseases
Giddens, J., Douglas, J. P., & Conroy, S. (2022). The Revised AACN Essentials: implications for
nursing regulation. Journal of Nursing Regulation, 12(4), 16–22.
https://doi.org/10.1016/s2155-8256(22)00009-6
Joo , J. Y., & Liu , M. F. (2021). Effectiveness of transitional care interventions for chronic
illnesses: A systematic review of reviews. Applied Nursing Research, 61, 151485.
https://doi.org/10.1016/j.apnr.2021.151485
Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon,
C. (2021). Nursing care coordination for patients with complex needs in primary
healthcare: a scoping review. International Journal of Integrated Care, 21(1), 16.
https://doi.org/10.5334/ijic.5518
Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S.,
Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing
8
care transition teams to mitigate hospital readmissions and improve patient outcomes.
Cureus, 15(5). https://doi.org/10.7759/cureus.39022