DUNI PP

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

Phase IV

Student name: Dunia Barrueta

Institution : Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: February 16, 2026

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

Abstract

Re-hospitalization in elderly patients with heart failure is also a problem that has persistently affected healthcare, and it is greatly affected by the gaps in the transitional care processes between hospitals and home. Fragmented discharge procedures, a lack of education on the use of medicines and managing symptoms, and post-discharge follow-up are common among older patients. These gaps help to cause drug errors, incorrect self-care compliance, higher emergency department visits, and avoidable 30 readmissions. Some interventions have proven to be effective in the context of structured, nurse-led transitional care, still, inconsistencies in their application do influence patient outcomes in clinical facilities. The focus of this project was the efficacy of a nurse-directed discharge planning and organized system of post-discharge follow-up intervention in aiding to lessen hospital readmissions in individuals diagnosed with heart failure, over 65 years of age. The study was a quantitative quasi-experimental pretest-posttest design of comparison with 120 participants who are to be allocated into an intervention group and compared with a control group that will be allowed to receive the usual discharge care. The major indicators were 30-day readmission to the hospital and visits to the emergency department. Secondary outcomes evaluated self-care behaviors and by following up services punctually. The results reported that individuals who went through the intervention led by nurses had considerably fewer readmissions and were less likely to visit the emergency department in 30 days after discharge. Also, self-care practices and increased follow-up of medical follow-ups were reported as better in the intervention group. Such findings justify the contribution of nurses to facilitate the coordination of care, encourage symptom surveillance, and increase patient involvement at transitional care phases.

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.

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).

Results

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. 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.

Implications for Nursing Education and the Nursing Profession.

The implications of this project for nursing education and practice are important as the findings are vital. The nursing curriculum must allow more emphasis on transitional care skills such as discharge planning, medication reconciliation, follow-up, structured follow-up, and chronic disease management patient education. Experiences of interprofessional collaboration, case-based learning, and simulation exercises can contribute to the development of clinical judgment and communication skills required by the students managing the complex process of hospital-to-home transition. Training on quality improvement, population health, and data analysis should also be introduced into graduate and advanced practice programs to make nurses capable of assessing readmission trends and becoming the leaders in evidence-based care programs.

To the nursing profession, the findings support the leadership position of vital importance that nurses have in lowering hospital readmission rates and enhancing continuity of care. Nurse-led models of transitional care can be shown to increase patient outcomes, leading to an increase in autonomy and expanded functions of transitional care in the healthcare system. Another important issue that healthcare organizations need to consider is the implementation of standardized practices of nurse-led discharge and following processes to guarantee patient safety and cost-effectiveness. In general, the reinforcement of education and professional development in transitional care will enable nurses to achieve better self-management outcomes, minimize avoidable readmissions, and enhance high-quality and patient-centered healthcare delivery.

Conclusion

Transitional care gaps still play a role in avoidable readmission stressors to hospitals in older adults suffering heart failure, indicating a requirement of systematic, evidence-based mitigation steps. In this project, it was shown that nurse-led discharge planning and timed follow-up contact with patients in the post-discharge phase can produce a positive change in the reduction of 30-day readmission, the decrease in emergency department usage, and the enhancement of self-care habits and treatment compliance. Nurses can take center stage in enhancing continuity of care by focusing on individualized education, medication reconciliation, and early symptoms monitoring to reinforce the hospital-to-home transition, which is a sensitive procedure.

The results indicate that the implementation of an organized approach to the use of standardized nurse-led transitional care models in clinical practice can improve patient safety, quality improvement, and healthcare costs reduction. On the whole, the development of nurse-led interventions in transitional care is a way to enhance patient outcomes as well as to strengthen leadership of nursing in providing coordinated and patient-centered care.

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

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

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

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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

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