YISEL PP

1

Phase 2 Assignment

Student name: Yisell Gonzalez

Institution : Florida National University

Course: Nursing Research and Evidence-Based Practice.

Instructor: Aciel Sagrera Mulen

Date: January 26, 2026

Improving Transitional Care for Heart Failure Patients

Brief Literature Review

Readmissions during hospitalization are high rates among patients with heart failure (HF), as it has been a significant issue for the healthcare systems worldwide. Approximately 20-25 percent of HF patients experience readmission within 30 days of discharge, which is typically associated with a fragmented transition process (Chartrand et al., 2023). Transitional care involves a complex set of actions within a restricted timeframe, with the purpose of providing continuity and coordination of patient transitions across medical facilities, including hospital-to-home. Low-quality transitional care is the reason behind medication inconsistencies, low ability to manage symptoms, lack of follow-up, and misunderstanding about self-care roles by the patient (Xie et al., 2022).

According to Feng et al. (2025), structured transitional nursing interventions can be very successful as a way to counter these risks. Patient-centered education based on discharge education has been identified to positively impact patient self-management behaviors and medication and nutritional adherence (Chartrand et al., 2023). Discharge planning, primarily managed by nurses, including personalized education, written instructions, and outlining follow-up plans, has an enormous impact on preventable readmissions. Besides, shared communication between community-based clinicians and hospital providers is also defined as one of the key aspects of effective transitions, which would reduce the rate of loss of information when changing care (Li et al., 2024).

Li et al. (2024) in their study found that post-discharge follow-up interventions also enhance the transitional care outcomes. Follow-ups by registered nurses through telephone within 48-72 hours of discharge help identify symptom exacerbation, medication problems, and unsatisfied social needs as early as possible. Randomized controlled trials suggest that these follow-ups can minimize emergency department visits and readmissions of HF patients in hospitals.

Furthermore, Liu et al. (2023) in their study found that transitional care models that combine nursing, primary care, or community resource utilization are better in-patient satisfaction and quality-of-life outcomes, as shown to be multidisciplinary. The literature, in general, highlights the point that nurse-led transitional care initiatives are evidence-based strategies to lower the number of HF readmissions and enhance patient safety.

Methodology and design of the study

The research design of the proposed study will be a mixed-method research design with the aim of thoroughly assessing the effectiveness of structured transitional nursing interventions to reduce 30-day readmission rates among HF patients. The quantitative part will use a quasi-experimental design where the results of the patients who have undergone regular discharge care and those who have undergone a structured transitional nursing program will be compared. During this program, standardized discharge education, medication reconciliation, some follow-up appointments, and post-discharge telephone assistance will be involved.

For quantitative data, the data will be collected in the form of a retrospective review of electronic health records (EHRs) to offer baseline data, whereas prospective data will be collected after the implementation of the intervention. For qualitative data, semi-structured interviews will be conducted on the selected participants receiving the intervention and will give insight into the perceived effectiveness, the clarity of discharge instructions, and the effects of nursing support on the transition process. Quantitative findings and qualitative experiences will help to have a more detailed impression of both the quantifiable effectiveness and patient-centered attitudes, which, in turn, are in line with the principles of the evidence-based nursing practice (Liu et al., 2023).

Sampling Methodology

A mixed sampling method will be applied in this study. In the case of the quantitative component, a convenience sample of adult patients with a heart failure diagnosis and discharged from an acute care hospital will be used. The inclusion criteria will consist of a confirmed diagnosis of HF, age 18 years and older, and home discharge. All the patients will be excluded as they will be sent to long-term care or hospice care facilities to limit confounding factors.

In the qualitative part, purposive sampling will be used to identify the people in the intervention group who will be interested in discussing their experiences. This will mean that the participants will be in direct exposure to the structured transitional nursing interventions under study. The power analysis will be used to determine the sample size to be used in the quantitative component in order to achieve a satisfactory level of statistical significance, and qualitative sampling will be done until a state of data saturation is reached.

Necessary Tools

There are several data collection instruments that will be required in this work. The EHR will offer the quantitative data in the form of readmission rates, demographics, and clinical indicators. The medication adherence will be addressed with the help of the self-report measures, such as the Morisky Medication Adherence Scale, which was validated. The adherence to following the appointment will be screened with the follow-up clinic attendance records.

In the case of the qualitative element, a semi-structured interview guide is going to be designed relying on the frameworks of transitional care and available literature (Liu et al., 2023). The interviews will be audio-taped and transcribed word-for-word to be analyzed thematically. Moreover, there will be standardized discharge education checklists and telephone follow-up scripts as means of intervention to be consistent for all participants.

Algorithms and Flow Maps

A transitional care flow map detailing the nursing activities, including admission until 30 days even after discharge, will be created to support the implementation of standardization. The algorithm will consist of some of the most important steps, i.e., patient identification, discharge readiness assessment, delivery of education, medication reconciliation, follow-up appointment scheduling, and post-discharge telephone calls. Process visual mapping leads to greater consistency, less variability in practice, and implementation of evidence-based guidelines (Taylor et al., 2025). These tools are important in the translation of research discoveries to an improvement of sustainable nursing practice.

Conclusion

In summation, this essay shows that low-quality transitional care is the reason behind medication inconsistencies, low ability to manage symptoms, lack of follow-up, and misunderstanding about self-care roles by the patient. Therefore, transitional care helps in addressing the issue of readmissions during hospitalization. Transitional care involves a complex set of actions within a restricted timeframe with the aim of providing patient’s transition and coordination across medical facilities, including hospital-to-home. Structured transitional nursing interventions are a viable solution to the high-patient readmission rates in heart failure patients. This literature review shows that patient and family-centered education, proper discharge planning, and active post-discharge follow-up helps in reducing care fragmentation and ensuring continuity across environments.

References

Chartrand, J., Shea, B., Hutton, B., Dingwall, O., Kakkar, A., Chartrand, M., Poulin, A., & Backman, C. (2023). Patient- and family-centred care transition interventions for adults: a systematic review and meta-analysis of RCTs. International Journal for Quality in Health Care, 35(4). https://doi.org/10.1093/intqhc/mzad102

Feng, Z.-F., Liu, Y., Salvador, J. T., Bravo, M., Ann, M., Huang, X.-Y., Zhang, L., & Liu, S. (2025). Implementation and evaluation of hospital-to-home transitional care intervention in patients with chronic heart failure. BMC Nursing, 24(1). https://doi.org/10.1186/s12912-025-03447-5

Li, W., Shi, S., Shi, Y., Feng, X., Li, Y., Guo, Y., Xu, J., Cui, L., & Wang, M. (2024). Exploring Stakeholder Perspectives on the Transitional Care Needs of Elderly Patients from Hospital to Home: A Phenomenological Study in Shanxi Province, China. Journal of Multidisciplinary Healthcare, Volume 17, 5457–5471. https://doi.org/10.2147/jmdh.s484187

Liu, S., Xiong, X., Chen, H., Liu, M. L., Wang, Y., Yang, Y., Zhang, M., & Xiang, Q. (2023). Transitional Care in Patients with Heart Failure: A Concept Analysis Using Rogers’ Evolutionary Approach. Risk Management and Healthcare Policy, 16, 2063–2076. https://doi.org/10.2147/rmhp.s427495

Taylor, N., Mazariego, C., Baffsky, R., Liang, S., Wolfenden, L., Presseau, J., Fontaine, G., Carland, J. E., Shiner, C. T., Wise, S., Debono, D., McKay, S., Best, S., & Morrow, A. (2025). Advancing the Speed and Science of Implementation Using Mixed-Methods Process Mapping – Best Practice Recommendations. International Journal of Qualitative Methods, 24. https://doi.org/10.1177/16094069251340908

Xie, xiaoqi, Chen, Q., & Liu, H. (2022). Barriers to hospital-based phase 2 cardiac rehabilitation among patients with coronary heart disease in China: a mixed-methods study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-01115-6