An algorithm to guide the transition of care for the heart failure patient: A quality improvement project

Purpose:The increase in hospital re-admission rates is a national concern. Patients aged 65 years and olderwith chronic health conditions, such as heart failure (HF), have high rates of 30-day hospitalreadmissions. This issue was observed in a palliative care organization, whereby a traditionalhospital discharge model was followed. A gap in the literature was using a nurse practitioner(NP)-led transition of care model (TCM) to tackle this problem. A DNP scholarly project wasimplemented with the aim of decreasing hospital readmissions for HF patients.Methods:A NP-led TCM was designed, which included a quality tool to manage HF patients after beingdischarged home. A pre-test/post-test design was utilized to compare hospital readmission datafollowing use of the NP-led TCM model. Feasibility and efficacy of the tool were also assessed.Results:Following the implementation of the NP-led TCM, hospital readmission rates for HF patientsdecreased to zero. Findings also supported the tool’s efficacy.Discussion:Compared to a traditional hospital discharge model, the NP-led TCM reduced hospital re-admission rates for HF patients. Findings from this project can add to the current body ofevidence regarding strategies to mitigate hospital re-admission rates for elderly patients withchronic conditions. As a result, hospitals will be more likely to receive quality incentives andprevent reimbursement penalties associated with readmissions and the lives of this vulnerablepopulation may be improved.