PHASE 3 DUN

Improving Transitional Care for Older Adults with Heart Failure Through Nurse-Led Discharge Planning and Follow-Up.

Phase I Assignment

Student name: Dunia Barrueta

Institution: Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: January 15, 2026

Improving Transitional Care for Older Adults with Heart Failure Through Nurse-Led Discharge Planning and Follow-Up

Introduction to the Problem

One of the main areas of healthcare provision mainly to the elderly with chronic diseases such as heart failure is transitional nursing care. Hospital-home transition is a time of increased vulnerability when patients tend to receive disjointed care, lack of education, and lack of healthcare coordination between the healthcare professionals. Heart failure is still one of the most common causes of hospitalization and re-hospitalization among the elderly population which imposes a significant burden on patients, families, and medical systems. It has been shown that poor quality of transitional care is a significant contributor to avoidable readmission and negative outcomes. Based on the recent systematic reviews, structured transitional care interventions (especially when guided by nurses) can decrease readmission rates and enhance patient-centered outcomes in patients with heart failure (Li et al., 2021; Rasmussen et al., 2021). Regardless of the accumulating evidence, transitional nursing practices are not fully put into practice, which indicates the necessity of specific research on the topic.

Clearly Identifying the Problem

The exact issue this project seeks to resolve is the high hospital readmission among heart failure patients aged above 65 years old due to the lack of a proper nurse-led transitional care. Most of the patients are released without having adequate knowledge of medication alterations, symptom surveillance, or follow-up medical care. Moreover, a lack of post-discharge support usually leads to a lack of self-care management and timely observation of symptom worsening. There is systematic evidence to indicate that without structured transitional care interventions, the older patients are more susceptible to medication errors, exacerbated symptoms, and premature re-hospitalization (Rasmussen et al., 2021). Despite the existence of transitional care models, their inadequate usage and inconsistency in the nursing practice remain a threat to the continuity of care among this susceptible group of the population.

Significance of the Problem to Nursing

The issue is also of great concern to the nursing profession as nurses are at the core of the care transition, patient education and continuity of care across healthcare environments. It has been demonstrated that nurse-led interventions in transitional care have a significant positive effect on the clinical outcomes of patients with heart failure, such as a decrease in readmissions and changes in functional status and self-management (Koontalay et al., 2024). The solution to this problem is in line with the role of nursing in enhancing patient safety, quality of care, and vulnerable populations. As systems are concerned, preventing unnecessary readmissions also helps healthcare organizations address their objectives regarding quality enhancement and cost control. Enhancement of nurse-led transitional care practice can boost the autonomous practice of professional nurses and offer an indication of the worth of nursing interventions on the promotion of better population health outcomes.

Purpose of the Research

This research aims at studying the usefulness of nurse-led discharge planning with a structured post-discharge follow-up in the prevention of hospital readmission among elderly patients with heart failure. The objective of this research is to determine the effects of individualized education, medication reconciliation, and early follow-up contact as transitional nursing interventions in improving patient outcomes in the process of hospital discharge to home environment. The research will also inform the evidence-based nursing practice through the synthesis of the available evidence and placement of the effective elements of the transitional care in patients facing heart failures to promote the development of standardized transitional care guidelines (Al Sattouf et al., 2022; Li et al., 2021).

Research Questions

The following research questions lead to this project:

How does nurse-led transitional care intervention influence hospital readmission of older adults with heart failure?

What role does structured post discharge follow-up by nurses play in influencing patient self-care and symptom management?

What are the most effective elements of nurse-led transitional care in enhancing the outcome of the hospital-home transition of heart failure patients?

Master’s Essentials Aligned with the Topic

The subject matter of this paper is consistent with several AACN Master Essentials. Essential I, (Background for Practice based on Sciences and Humanities), can be seen through the combination of the latest research evidence to solve the complicated transitional care issues. Essential II, (Organizational and Systems Leadership), is tackled by working on enhancing discharge procedures and decreasing readmission on the system level. Essential III, (Quality Improvement and Safety) is directly justified by the focus on the prevention of avoidable re-hospitalizations and enhancement of the continuity of care. Moreover, Essential VII, (Interprofessional Collaboration), is also applicable because transitional care needs co-ordinated communication between nurses and physicians and patients and caregivers. All these necessities are useful towards the leadership role of the advanced practice nurse in enhancing the outcomes of transitional care.

Conclusion

Conclusively, ineffective handover of older adults with heart failure is an important nursing and healthcare issue that leads to avoidable readmission of patients. The effectiveness of nurse-led interventions in transitional care is strongly supported to improve patient outcomes and reduce the rate of re-hospitalization. The process of discharge planning and post-discharge follow-ups are some of the areas that nurses can play a significant role in enhancing self-management and continuity of care in patients. The project is based on the combination of the existing evidence, nursing leadership principles, and quality improvement targets to close a critical gap in the field of transitional care. The development of nurse-led transitional care practice has the potential to deliver a beneficial impact on the patient outcome, the nursing practice, and the creation of more efficient and patient-centered healthcare systems.

References

Al Sattouf, A., Farahat, R., & Khatri, A. A. (2022). Effectiveness of Transitional Care Interventions for Heart Failure Patients: A Systematic Review With Meta-Analysis.  Cureus,  14(9). https://doi.org/10.7759/cureus.29726

Koontalay, A., Samai, T., Samutalai, C., Onthuam, W., & Fonghiranrat, D. (2024). Effectiveness of Nurse-led Heart Failure Transitional Care Services in Improving Clinical Outcomes and Applicability to Low-resource Settings: A Meta-analysis.  WHO South-East Asia Journal of Public Health,  13(2), 60–68. https://doi.org/10.4103/WHO-SEAJPH.WHO-SEAJPH_26_23

Li, Y., Fu, M. R., Fang, J., Zheng, H., & Luo, B. (2021). The effectiveness of transitional care interventions for adult people with heart failure on patient-centered health outcomes: A systematic review and meta-analysis including dose-response relationship.  International Journal of Nursing Studies,  117, 103902. https://doi.org/10.1016/j.ijnurstu.2021.103902

Rasmussen, L. F., Grode, L. B., Lange, J., Barat, I., & Gregersen, M. (2021). Impact of transitional care interventions on hospital readmissions in older medical patients: A systematic review.  BMJ Open,  11(1). https://doi.org/10.1136/bmjopen-2020-040057