PHASE 3 DUN

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

Phase 2 Assignment

Student name: Dunia Barrueta

Institution : Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: January 26, 2026

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

Introduction

The problem of hospital readmissions in older adults with heart failure continues to pose a major challenge to the healthcare systems in most countries globally and this is mostly as a result of gaps in the transitional care provided during the discharge of the patient. The transition phase after hospitalization is characterized by the restructuring of the treatment regimens, the decrease in the clinical supervision, and the increment of the self-management of treatment, which increases the vulnerability of the patients. It has been proved that weak discharge education, lack of medication reconciliation and unstructured follow-up have a significant role in unwarranted readmissions. Nurse-led transitional care interventions have emerged as an effective tool of addressing these gaps by enhancing care coordination, training patients, and early identification of symptoms. This paper is aimed at promoting the concept of nurse-led transitional care of older adults with heart failure and outline a research study methodology, sampling plan, data collection tools, and models of care to determine the efficiency of the formalized nurse-led discharge management and follow-up.

Brief Literature Review

The interventions of transitional care among heart failure patients have been extensively researched because they are related to the reduced readmissions to hospitals and enhanced patient outcomes. One of the most prevalent reasons of hospitalization and re-hospitalization among the older population and disproportionately among older population is heart failure. Differentiation into home often results in medication errors, home inadequate monitoring of symptoms and lack of patient knowledge regarding self management. The high level of effectiveness is provided to the transitional care interventions of the heart failure patients. The study by Li et al. (2021) revealed that the effects of transitional care interventions on hospital readmission and patient-centered outcomes (self-care behaviors and quality of life) are meaningful in a systematic review and meta-analysis. The results also demonstrated a dose response correlation that revealed interventions of higher intensity and frequency of follow up were correlated with better results.

Transitional care models that have been developed by nurses have demonstrated uniform advantages in various healthcare environments. According to Koontalay et al. (2024), heart failure transitional care services led by nurses have been shown to have a high reduction in rehospitalization rates and clinical outcomes, despite operating in low-resource settings. These results highlight the importance of nurses in the discharge education, care coordination, and follow-up provision. Likewise, Sakashita et al. (2025) had a similar result, which included that nurse-led transitional care intervention showed better continuity of care and fewer adverse post-discharge events, which continues to support the effectiveness of the nurse-driven models. It has been found that the older adult population is particularly sensitive to the structured transitional care interventions. Rasmussen et al. (2021) discovered that older medical patients experiencing transitional care interventions were also associated with a drastic decrease in their hospital readmission rate, which also highlighted the need for standardized discharge processes and post-discharge support. These results are very applicable to patients with heart failure conditions at the age of 65 years and above because they are likely to be multimorbid and undergo complex medication regimes.

It has been found that discharge planning is an essential part of effective transitional care. The study performed by Ruksakulpiwat et al. (2025) indicated that interventions based on structured discharge planning and intervention among patients with heart and other chronic diseases enhanced continuity of care and minimized the risk of readmission. Al Sattouf et al. (2022) also found that transitional care interventions that included discharge education and follow-up at an early age were effective in enhancing self-management and lessening rehospitalization in patients with heart failure. Together, the literature is highly in favor of nurse-led discharge planning and follow-up as an evidence-based measure of enhancing transitional care outcomes.

Methodology and Design of the Study

The study will utilize a quantitative quasi-experimental study design to test the hypothesis on the effectiveness of a nurse-led discharge planning and structured follow-up intervention in the framework of the decrease in the number of hospital readmission cases among older adults having heart failure. The use of a quasi-experimental design can be explained by ethical and operational limitations in the clinical setting because random assignment can narrow the access to beneficial interventions.

A pretest posttest comparison study design will be used in the study where affected interventions will be an intervention group and a comparison group that will receive normal discharge care. The intervention group will be provided with personalized nurse-led discharge education, full medication reconciliation, written self-care education, and scheduled follow-up contacts by the registered nurses at 72 hours post-discharge and weekly during 30 days. Comparison of outcomes will be done to evaluate the effectiveness of interventions between groups.

The key outcome measures will be 30-day readmissions and emergency department. The patient self-care behaviours and adherence to follow up appointments will be considered as secondary outcomes. This design assists in measuring the association between nurse-led transitional care and patient outcomes but feasible in the regular healthcare delivery.

Sampling Methodology

The quantitative sampling method will be involved in this research. The sample population will be in the form of patients between the ages of 65 and older who have been admitted in the hospital and the chief diagnosis is heart failure and are discharged to go home. In the acute care hospital, the participants will be recruited by using the convenience sampling technique. The criteria to be included will include a confirmed diagnosis of heart failure, discharge to non-institutional setting, and informed consent. The exclusion criteria will be discharge to skilled nursing facilities, hospice care, and severe impairment of cognitive function that prevents delivering education and follow-up. The power analysis will inform the determination of the sample size as it will provide adequate statistical power. Such a sampling method aligns with previous studies on transitional care in the context of older patients with heart failure (Li et al., 2021; Rasmussen et al., 2021).

Necessary Tools

There will be a number of standardized tools to help in data collection and intervention consistency. The data on hospital readmission and emergency department visit will be obtained out of electronic health records. The self-care behaviors of patients will be measured through a validated heart failure self-care instrument on evaluation of maintenance, management, and confidence of self-care activities. The process of providing education at discharge regarding medication management, symptoms recognition and dietary limitations and follow-up will be standardized with the help of a nurse-led discharge checklist. Structured telephone assessment templates will be used as a follow-up measure to report the status of symptoms, medication compliance, and the necessity to escalate care. The tools promote reliability, validity, and fidelity of the intervention (Koontalay et al., 2024; Ruksakulpiwat et al., 2025).

Algorithms or Flow Maps Created

A transitional care flow map that will be led by a nurse will be created to facilitate the intervention. The flow chart will describe the identification of patients, the elements of discharge education, medication reconciliation, and follow-up contacts arrangements and the escalation routes in case of worsening of the symptoms. The algorithm will visually present the transition between the inpatient care and home, showing the points of nurse-led decisions and communication with providers. Flow mapping aids in the provision of standard care delivery, interprofessional coordination, and the improvement of quality. Structured care algorithms are proven to enhance the intervention fidelity and transitional care outcomes (Rasmussen et al., 2021; Sakashita et al., 2025).

Conclusion

There is a solid rationale in favor of nurse-led transitional care as the approach to better outcomes in case of older patients with heart failure. The literature depicts that with the aid of structured discharge planning and follow-up after discharge, hospital readmissions are reduced, self-care behaviors are better, and continuity of care. The suggested quantitative quasi-experimental investigation is based on this evidence and involves the assessment of a standardized nurse-led intervention and its validated tools and structured care algorithms. The outcomes of the study can inform the implementation of the evidence-based nursing practice, support the models of the transitional care, and contribute to the improvement of patient safety, quality of care, and efficiency of the healthcare system.

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

Ruksakulpiwat, S., Benjasirisan, C., Phianhasin, L., Koson, N., Chei, N., Rounratana, T., Saenkla, P., & Thampakkul, J. (2025). Effectiveness of Discharge Planning Interventions for Stroke and Heart Conditions: A Systematic Review of Interventional Studies.  Journal of Multidisciplinary Healthcare,  Volume 18, 7521–7537. https://doi.org/10.2147/jmdh.s563476

Sakashita, C., Endo, E., Ota, E., & Oku, H. (2025). Effectiveness of nurse-led transitional care interventions for adult patients discharged from acute care hospitals: a systematic review and meta-analysis.  BMC Nursing,  24(1). https://doi.org/10.1186/s12912-025-03040-w