Science Powerpoint assignment

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Reducing Hospital Readmissions Among Patients with Heart Failure Through Nurse-Led Transitional Care

Reducing Hospital Readmissions Among Patients with Heart Failure Through Nurse-Led Transitional Care

Health Care Issue or Problem

Heart failure is a significant health care issue and is a condition that needs to be managed on an ongoing basis following hospitalization. Heart failure patients often have problems taking medications, self-monitoring, adhering to diets, and noticing the early signs of worsening heart failure. These are problems that may lead to complications, emergency department visits, and hospital readmissions. Nurses have an important role in patient education, discharge planning, symptom assessment, medication management, and coordination of follow-up, making the problem particularly relevant to nursing. Kleman et al. (2024) identified a combination of individual and health-system factors to affect Heart failure self-care, suggesting a need for ongoing support after discharge. Thus, enhancing transitional care can be an opportunity for the nurse to also address barriers to self-management and build the skills of patients to manage Heart failure at home.

There is evidence of the effectiveness of structured interventions in the transition from hospital to home. Longhini et al. (2025) discovered that nursing interventions to enhance Heart failure self-care at home can have a positive impact on the patients' capacity to take care of their condition at home. Interventions can range from education, through telephone support, all the way to home-based care or other methods that keep patients connected with health professionals after discharge. Further, non-invasive home telemonitoring has been shown to help manage decompensated Heart failure by enabling the assessment of clinical information at home (Drews et al., 2021). A nurse-led transitional-care intervention (standardized education and early telephone or telehealth follow-up) is potentially an effective evidence-based intervention for improving post-discharge care.

Target Population

The adult patients discharged from an acute-care hospital with heart failure and at high risk for hospital readmission will be the target population for this intervention. This population is suitable since moving from hospital to home may pose a challenge for patients who are expected to manage a complex chronic condition on their own. Patients might struggle with comprehending the medication adjustments, maintaining self-care practices, tracking their weight and symptoms, or knowing when to seek help. The individual and system-related factors identified by Kleman et al. (2024) suggest that patients’ knowledge and abilities, and their access to the health care system, are key to successful Heart failure self-care.

This proposed intervention will offer discharge education, medication, and symptom-management teaching to patients, reinforcement of self-care behaviors, and will include scheduled nurse follow-up using a phone or telehealth communication. In addition, Longhini et al. (2025) proved that nursing interventions can have a positive impact on Heart failure self-care at home, and telemonitoring evidence shows that remote monitoring can be used to provide clinical support outside of the hospital (Drews et al., 2021). Telemedicine-based interventions can also help to improve outcomes and provide ongoing follow-up and patient communication after discharge (Stergiopoulos et al., 2024). These results are congruent with the suggestion to target recently discharged Heart failure patients with a coordinated nurse-led intervention.

PICO Questions

This project will be developed and implemented using the PICO framework. The population (P) will be adult patients who have been discharged from an acute-care hospital with heart failure. The intervention (I) will be a nurse-led transitional care model that includes standardized discharge education, medication and symptom management education, and early (telephone or telehealth) follow-up care. The intervention (I) will be usual post-discharge care; the comparison (C) will be reduced 30-day hospital readmissions and improved heart failure self-care; and the outcome (O) will be reduced 30-day hospital readmissions and improved heart failure self-care. Longhini et al. (2025) believe that structured nursing interventions that will provide ongoing education, monitoring, and support for self-care can enhance patients' capacity to manage heart failure after discharge. This evidence supports the appropriateness of a nurse-led transitional-care program to solve the problem identified.

The primary PICO question is: Can a nurse-led, transitional-care program, which uses a nurse-led, patient-focused, standardized education and early follow-up via telephone or telehealth, reduce 30-day hospital readmissions in adults with heart failure discharged from an acute-care hospital compared to usual post-discharge care? The secondary question is: Does nurse-led transitional care help adults to make more self-care and symptom-management behaviors after a heart failure hospitalization than usual care? These questions provide measurable outcomes for the implementation plan. Drews et al. (2021) identified home telemonitoring as a means to support the management of patients with decompensated heart failure, and Stergiopoulos et al. (2024) explored telemedicine and telemonitoring interventions in the context of readmissions in patients with heart failure. So, the use of the telephone or telehealth follow-up in the proposed nursing intervention was incorporated.

References

Drews, T. E., Laukkanen, J., & Nieminen, T. (2021). Non-invasive home telemonitoring in patients with decompensated heart failure: A systematic review and meta-analysis. ESC Heart Failure, 8(5), 3696–3708. https://doi.org/10.1002/ehf2.13475

Kleman, C., Turrise, S., Winslow, H., Alzaghari, O., & Lutz, B. J. (2024). Individual and systems-related factors associated with heart failure self-care: A systematic review. BMC Nursing, 23(1), 110. https://doi.org/10.1186/s12912-023-01689-9

Longhini, J., Gauthier, K., Konradsen, H., Palese, A., Kabir, Z. N., & Waldréus, N. (2025). The effectiveness of nursing interventions to improve self-care for patients with heart failure at home: A systematic review and meta-analysis. BMC Nursing, 24(1), 286. https://doi.org/10.1186/s12912-025-02867-7

Stergiopoulos, G. M., Elayadi, A. N., Chen, E. S., & Galiatsatos, P. (2024). The effect of telemedicine employing telemonitoring instruments on readmissions of patients with heart failure and/or COPD: A systematic review. Frontiers in Digital Health, 6, 1441334. https://doi.org/10.3389/fdgth.2024.1441334