Transitional Care Intervention for Heart Failure Patients to Reduce Hospital Readmissions












Transitional Care Intervention for Heart Failure Patients to Reduce Hospital Readmissions

Student: Kenya Leyva

Institution: South University



Heart failure (HF) is one of the most significant causes of admission in hospitals and the associated readmission in older adults. Research shows that 20 to 25 percent of patients treated with HF is likely to be re-hospitalized within 30 days (Ross et al., 2010). The rate increases to 50% for six months. However, data shows that most of these readmissions can be prevented. An approach to reduce hospital readmissions has been a significant pillar in reforming Medicare, including the 30-day risk-adjusted measures after a patient is discharged.

Background and significance of the problem

Heart failure is a leading cause of hospitalization and hospital bills in the United States. Data collected by the Centers for Medicare and Medicaid Services (CMS) shows that HF is the third highest cause of reimbursements and also the most common principal discharge diagnosis. Transitional care interventions have emerged to prevent readmission among HF patients. The CMS attempts to curb this problem in hospitals with extreme risk-standardized readmission tolls.

A significant focus in the modern health care systems is the care for chronic conditions, including heart failure. The Hospital Readmissions Reduction Program has also been addressed through the Affordable Care Act of 2010. Together with the Social Security Act, this law requires CMS to punish hospitals with exceptionally high numbers of readmitted patients by reducing their payments (Gupta et al., 2018). This law took effect on 1st October 2012 and shows the relevance of redesigning the hospital discharge processes.

The primary reasons for readmissions of heart failure patients are noncompliance to medication and diet, late recognition of symptoms, and lack of self-care knowledge. Comprehensive discharge planning is likely to yield better results for older adults with more than 25% reduced risk of readmission. The cost of hospitalization directly reduces if proper education and interventions are made to heart failure patients. Aspects such as the failure of adherence to diet and medication for patients with chronic conditions may not only contribute to readmission but also early mortality.

Proper discharge planning and adequate patient education can promote compliance and improve the outcomes of the patients. The primary focus of planning is to make patients participate actively in their self-care. Discharging a patient and accompanying him/her with educative guidelines is critical to improving the aftermaths of heart failure treatment (Ross et al., 2010). The patients and their families can be educated on adherence to medication, daily weights, sodium and fluid restrictions, smoking cessation, activity tolerance, symptoms of worsening heart failure, and sodium and fluid limitations.

Statement of the problem and purpose of the study

This is an evidence-based project that has been developed to reduce readmission rates of HF patients by increasing their knowledge and intervening in personal-care activities. The project focuses on eliminating preventable readmissions of Medicare beneficiaries by incorporation of best practices regarding education.

This research is crucial at a time when a patient-centered approach is largely identified as an essential factor in improving the healthcare system and applicable policies (Gupta et al., 2018). The purpose of the study is to investigate the effectiveness of transitional care interventions as a means of preventing hospital readmissions for patients treated with heart failure. This quantitative study was

Research questions

1. Do transitional care interventions increase or decrease hospital readmission for patients with heart failure?

2. Does the intervention lower or increase the mortality rate?

3. How is a patient follow-up associated with quality of life and other outcomes of the patient?


Disseminating knowledge to patients and their families about their heart failure management and intervention will reduce readmissions and improve outcomes.


The population for this study was adults with heart failure who required inpatient admission, followed by a 30-day post-discharge. The independent variable is a comparison of two groups: an intervention group and a control group. The intervention group contains 24 inpatients, where transitional care intervention was applied effectively. The intervention has been operationally defined as participants ranging from 27 to 90 years. The average years is 72, and the females were 47%, while the males were 53%. 32.7% are widowed, 46.9% are married, 8.2% are single, and 12.2% are divorced. They are all provided with learning materials and advised before being discharged. A Heart Failure clinic advanced practice nurse will teach them basic principles. All participants were taught in English, and they all spoke and read well.

The next dependent variable is a control group of 17 participants 30 days before the intervention is made. All variables cannot be measured since the data will be collected from medical records, and the comparison is based on post-discharge records. This group involves participants aged 66 to 95, a mean of 84 years. Most of them are male, and all of them were issued standardized educational tools for heart failure diagnosis. No further interventions will be made. The initial readmission rate for the control group before the new intervention was recorded to be 22.9%. This data is based on 30 days after discharging the HF patients.

The independent variables were the predischarge interventions. This refers to the proper planning of patients’ behaviour and activities prior to discharge. Educational materials regarding patients’ diagnosis of heart failure will be distributed to the intervention group and the control group. The aim is to investigate how different levels of transitional care interventions can impact on readmission rates among heart failure patients. More focus was given to the intervention group than the control group. Other interventions include medication reconciliation. The intervention group will be taught the importance of adherence to medication and the recommended diet. They will also be given an appointment before being discharged, which shows the intensive efforts of follow up practices. The patients are taught the signs and symptoms to watch out in case the heart failure condition is severe. This approach aims at reducing the readmissions associated with late recognition of a deteriorating condition. Thus, interventions can be used to prevent consequential premature deaths.

The expected results will be measured from health and social outcomes and health care utilization outcomes. The mortality rates will be recorded as well as the quality of life using a validated measure. The self-care and caregiver burdens will also be estimated. The rate of use of healthcare services will be recorded—for instance, heart failure readmissions and the visits in emergency rooms. Furthermore, subsequent readmissions on hospital days and acute-care visits are to be noted.

The timing of this study is 30 days from the day of hospital discharge. Although outcomes may be measured for three months, they are excluded from the result findings. Thirty days were chosen to conform to the CMS policy that monitors hospitals with a rampant readmission rate (Gupta et al., 2018). The outcomes to be assessed are the self-care knowledge, level of heart failure awareness, and the impacts of interventions on the frequency of emergency room visits, rehospitalizations, and deaths within three months (Ross et al., 2010). Telephone contacts were made for the intervention group, while none were used to monitor the control group.






Gupta, A., Allen, L. A., Bhatt, D. L., Cox, M., DeVore, A. D., Heidenreich, P. A., … & Fonarow, G. C. (2018). Association of the hospital readmissions reduction program implementation with readmission and mortality outcomes in heart failure. JAMA cardiology3(1), 44-53.

Ross, J. S., Chen, J., Lin, Z., Bueno, H., Curtis, J. P., Keenan, P. S., … & Wang, Y. (2010). Recent national trends in readmission rates after heart failure hospitalization. Circulation: Heart Failure3(1), 97-103.

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