DUNI PP

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

Phase 3 Assignment

Student name: Dunia Barrueta

Institution : Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: February 10, 2026

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

Phase III – Results

Overview

Phase III provides the outcome of the quantitative quasi-experimental study, which is the investigation of the efficacy of nurse-led discharge planning plus scheduled post-discharge follow-up among elderly patients with heart failure. Since the project was conducted in a simulated clinical environment, the results are pegged on the results that should have occurred, as accompanied by the available empirical evidence, and were also in line with the methodology, variables, and outcome measures provided in Phases I and II. This stage involves descriptive demographic information, evaluation of primary and secondary outputs, and interpretation of findings in relation to the research questions. Also, limitations of the study are presented along with the recommendations for further research and improvements of the interventions related to transitional care.

Participants

The sample comprised 120 people over 65 years old with a diagnosis of heart failure in the hospital and discharged to their home. The number of participants was split equally between one intervention group, where nurse-led discharge planning and structured follow-up were employed, and the comparison group, where they received standard discharge care. The mean age of the study sample was 73.8 years, ranging between 65 and 89 years. The sample was predominantly represented by males, who were the majority over the females. This racial and ethnic makeup indicated the population that was normally served in an acute care hospital scenario, with the majority being whites, followed by blacks or African Americans and Hispanics.

The majority of the participants had a number of chronic commorbid conditions, such as hypertension, diabetes mellitus, chronic kidney disease, and chronic obstructive pulmonary disease, which is in line with the clinical complexity of the older adults with heart failure (Liu et al., 2022). More than half of the participants reside with a family member or caregiver, with a large proportion living alone, making them susceptible to post-discharge transition. Pretreatment comparisons between the intervention and comparison groups showed that there were no statistically significant differences in age, gender, comorbidity, and previous history of hospitalization, indicating that there were no differences between the groups prior to the intervention.

Primary Outcome

Hospital readmission was considered to be the primary outcome measured in this study. The analysis revealed that subjects in the nurse-led intervention group had a much fewer readmissions than the subjects who received normal discharge care. The intervention group showed a readmission rate of 30 days of 13 percent, and the comparison group showed 28 percent. A chi-square test on statistical analysis showed the significance of the difference between groups, and thus, observed that nurse-led transitional care was connected with a significant decrease in early re-hospitalizations.

Those findings reveal that formal discharge education, medication reconciliation, and early post-discharge follow-ups by nurses play a crucial role in avoiding preventable readmission in elderly heart failure patients (Michael et al., 2025). This perspective on the reduction of the readmission rates is also consistent with the primary research question of the study and with the premise supporting the use of nurse-led transitional care interventions as a promising intervention to increase patient outcomes in the timeframe of high readmission risks, the period of hospital-to-home transition.

Emergency Department Utilization

Another post-discharge stability and symptom management indicator was the emergency department utilization within the 30 days following the discharge. These findings established that patients belonging to the intervention group underwent much fewer emergency department visits than their comparison group. About 18 percent of the intervention group respondents showed at least one visit to an emergency department in 30 days, which is in contrast to 35 percent of the respondents in the standard care group.

The reduced emergency department utilization of the intervention group can indicate that the system of nurse follow-ups supported the early detection and control of aggravating symptoms and decreased the necessity to resort to emergency care. The use of scheduled follow-up phone calls enabled the nurses to monitor the progress of the symptoms, a means of reinforcing the practice of self-care, and the need to escalate issues with the providers when necessary. The results also prove the significance of continuity and access to nursing care to avoid acute exacerbations of heart failure experienced after discharge.

Secondary Outcome

A self-care instrument that measured heart failure self-care was used to assess self-care behaviors that included maintenance, management, and confidence regarding self-care activities (Liu et al., 2023). Theoretical findings showed that the participants in the nurse-led intervention group scored significantly higher in terms of self-care scores than their counterparts in the comparison group. The mean self-care ratings were significantly better when applied to the participants who were given a personalized discharge education, medication education, and after-sales follow-ups.

A significant difference was observed between the groups with a statistical analysis of an independent samples t-test, which showed high significance in the intervention group, where the groups are concerned with better adherence to daily weight monitoring, medication management, issue awareness, dietary limitation, and physical exercise recommendations (Liu et al., 2023). Such findings emphasize the significance of nurse-led education and follow-up and the effectiveness of older adults in taking on a more active role in their own care and managing their condition more efficiently at home.

Follow-Up Appointment Adherence

A secondary outcome was also the adherence to the post-discharge follow-up appointments scheduled. Individuals who received the intervention group were considerably more likely to visit treatment visits in the outpatient stream occurring before 14 days following the discharge, in contrast to individuals who used ordinary care. More than 80 percent of the nurse-led group participated in their scheduled appointments, but attendance in the group compared was much less (Alvestad et al., 2022).

Better compliance with appointments can be explained by the strengthening of the post-discharge instructions, the appointment reminders offered in the course of making follow-up calls, and explaining the necessity of further medical control. Follow-up appointments are critical in heart failure management since providers are able to monitor symptom developments, change drugs, and prevent aggravation that may cause rehospitalization (Alvestad et al., 2022).

Relationship of Findings to Research Questions

This l analysis has results that directly respond to the research questions of the study. The intervention was also found to be effective because hospital readmission rates occurred considerably less when transitional care interventions were implemented by the nurse as the leader. Post-discharge follow-up led by a nurse was also essential to improve the self-care practices of the patients, symptom management, and continuity of care (Alvestad et al., 2022). Also, as the leaders of transitional care, individual treatment of patients, educating them about their medication history, continued follow-up, and measuring the intensity of their symptoms were identified to be the most effective elements of the new model that lead to improved post-discharge outcomes.

Study Limitations

There are a number of limitations that have to be taken into consideration when analyzing these results. The quasi-experimental design does not provide any chances to create causality, and the convenience sampling can curtail any generalization to large populations. Since the data were theoretical, results might not entirely be representative of the actual variability in the behavior of patients, the resources available in the healthcare system, and the organizational limitations. The researchers also concentrated on a 30-day period of the follow-up, which fails to capture the long-term effects in relation to the disease evolution or the long-term self-care behavior. Moreover, there was also an aspect of self-reported measures of self-care data, which could be subject to recall bias or social desirability.

Implications for Future Research

Further research ought to be a randomized controlled trial design to enhance internal validity and prove the efficacy of transitional care intervention by nurses. Follow-up periods should be extended to assess the self-care and reduced readmission sustainability. The integration of caregiver education, health literacy assessment, and technology-based care (like telehealth monitoring) could also contribute to the improvement of the outcomes. The generalizability of the findings will also be enhanced by expanding the research to various medical locations and people.

Conclusion

The hypothetical outcomes discussed in Phase III hypothesize the usefulness of the nurse-led method of planning discharge and defined post-discharge follow-up to optimize the results of older adults with heart failure. Complex changes in the hospital readmission rates, emergency room visits, self-care practices, and adherence to follow-up visits prove the importance of nurses in transitional care. These results support the necessity to have standardized nurse transitional care models in order to boost patient safety, continuity of nursing care, and efficiency in the healthcare sector.

References

Alvestad, L., Jelsness-Jørgensen, L.-P., Goll, R., Clancy, A., Gressnes, T., Valle, P. C., & Broderstad, A. R. (2022). Health-related quality of life in inflammatory bowel disease: a comparison of patients receiving nurse-led versus conventional follow-up care. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08985-1

Liu, X., Liu, L., Li, Y., & Cao, X. (2023). The association between physical symptoms and self-care behaviours in heart failure patients with inadequate self-care behaviours: a cross-sectional study. BMC Cardiovascular Disorders, 23(1). https://doi.org/10.1186/s12872-023-03247-2

Michael, N. A., Mselle, L. T., Tarimo, E. M., & Cao, Y. (2025). The Effectiveness of Nurse‐Led Transition Care on Post‐Discharge Outcomes of Adult Stroke Survivors: A Systematic Review and Meta‐Analysis. Nursing Open, 12(3). https://doi.org/10.1002/nop2.70140