YISEL PP

1

Phase I Assignment

Student name: Yisell Gonzalez

Institution: Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: January 15, 2026

Improving Transitional Care for Heart Failure Patients

Introduction

In healthcare, readmission of patients with heart failure (HF) to the hospital has been one of the most burning concerns across the entire world's healthcare systems. The issue of transitional care, or healthcare transfer between two healthcare settings, has been selected as one of the primary factors in reducing the number of adverse effects, including medication errors, ineffective treatment plan compliance, and unnecessary hospital readmission (Al-Tamimi et al., 2021). The gaps, which exist in the field of transitional care, should be perceived and applied to improve the overall nursing care quality and safety of patients.

Problem

Patients with heart failure have high readmission rates because nearly a quarter of the total number of patients are readmitted to the hospital within 30 days of discharge (Foroutan et al., 2023). This is the primary weakness in the practices of transitional care. Its reasons include the inappropriate education of patients on how to self-manage, a lack of agreement between the hospital workers and the community professionals, and, finally, a lack of coordination of the post-discharge treatment. These gaps are bound to cause adverse effects, including medication errors, escalation of the condition, and unnecessary readmission. Lack of standardized transitional care guidelines in all health facilities can only attest to the fact that research should be undertaken, which will evaluate evidence-based interventions that the nursing staff members can implement as a means of addressing the gap in care and continuity in patients with chronic conditions such as HF.

Implications of the Problem to Nursing.

Transitional nursing is essential to improve patient outcomes in times of care transitions when patients are at a vulnerable time. The nurses will be involved in informing the patients, following up on their appointments, evaluating the domestic surroundings, and the mechanism through which the hospital and the community providers communicate (Tyler et al., 2023). By providing continuity of care, nurses will be able to reduce the rate of hospital readmission, improve adherence to the treatment plan, and enhance patient satisfaction. Nursing is also interested in the field of practice as being directly impactful on patient safety and aligning with the principles of patient-centered care. The solution of the transitional care issue also contributes to the achievement of the overall goals of the healthcare reform to improve the health outcomes of the population and reduce the number of healthcare expenditures associated with preventable readmissions. Good transitional nursing intervention is beneficial not only to improve the performance of individual patients but also the performance of the health care systems as well.

Purpose of the Research

This research is expected to investigate the effectiveness of structured transitional nursing programs in preventing hospital admissions in patients with heart failure in the 30-day period. This paper will analyze some of the interventions that include discharge education programs, post-discharge telephone follow-ups, and the use of primary care and community resources. The ultimate goal is to determine evidence-based practices that could be adopted in nursing attention toward increasing patient outcomes, diminishing readmissions, and also boosting the quality of transitional care. The proposed study will inform about evidence-based practices that can be applied in different healthcare environments by emphasizing the nursing role in the context of transitional care to guarantee that HF patients receive safer and more effective transitions.

Research Questions

“What is the effectiveness of structured transitional nursing interventions in heart failure patients about reducing 30-day readmission of heart failure patients?” (Tyler et al., 2023)

What are the most effective transitional practices that will result in patient compliance with the discharge orders?

What are the perceptions of patients on the quality of transitional services and their effectiveness by nurses?

Master’s Essentials that Align with the Topic

This study is consistent with some of the AACN Master slide essentials in advancing nursing practice:

 Essential I: Liberal Education to Nursing Advanced Practice - It provides insight into the knowledge of the methods of studying the healthcare system, population health, and patient-centered care methods (Mackavey et al., 2025).

Essential II: Organization and Systems Leadership to develop harmonized and evidence-based interventions that can improve health services transition in health care systems.

Essential III: Clinical Scholarship, Analysis, and Evidence-Based Practice, and analytical approach.

Essential VI: Interprofessional Cooperation to Enhance Patient Health Outcomes

Essential VII: Population Health and Clinical Prevention to Improve Health - focuses on health prevention and promotion of health against readmissions and safety in patients.

Conclusion

In summation, planned transition nursing programs will increase treatment regimens compliance, decrease readmission, and improve patient satisfaction. By implementing such interventions and studies, this research will provide evidence-based recommendations that will be used to guide the nurses towards the adoption of the best practices in transitional care.

References

Al-Tamimi, M. A.-A., Gillani, S. W., Abd Alhakam, M. E., & Sam, K. G. (2021). Factors Associated With Hospital Readmission of Heart Failure Patients. Frontiers in Pharmacology, 12(12). https://doi.org/10.3389/fphar.2021.732760

Foroutan, F., Rayner, D., Ross, H. J., Ehler, T., Srivastava, A., Shin, S., Malik, A., Benipal, H., Yu, C. C., Lau, A., Lee, J. G., Rocha, R. V., Austin, P. C., Levy, D., Ho, J. E., McMurray, J. J. V., ZannadF., Tomlinson, G., Spertus, J. A., & Lee, D. S. (2023). Global Comparison of Readmission Rates for Patients With Heart Failure. Journal of the American College of Cardiology, 82(5), 430–444. https://doi.org/10.1016/j.jacc.2023.05.040

Mackavey, C., Henderson, C., & Morris, G. (2025). Empowering Advanced Practice Nurses: A Review of Addressing Global Health Needs. Annals of Global Health, 91(1), 45–45. https://doi.org/10.5334/aogh.4723

Tyler, N., Hodkinson, A., Planner, C., Angelakis, I., Keyworth, C., Hall, A., Jones, P. P., Wright, O., Keers, R. N., Blakeman, T., & Panagioti, M. (2023). Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes. JAMA Network Open, 6(11), e2344825–e2344825. https://doi.org/10.1001/jamanetworkopen.2023.44825