Date of Award

Fall 12-22-2015

Degree Type

Final Project

Degree Name

DNP Doctor of Nursing Practice




Mary Ellen Roberts, DNP

Committee Member

Judith Lucas, Ed.D

Committee Member

Mary Carroll, MSN


Throughout the nation, there is an increased focus on reducing preventable hospital readmissions. This initiative started with the Patient Protection and Affordable Care Act (PPACA) (CMS, 2014), which sets forth certain provisions for Medicare spending. Hospitals with higher than usual readmission rates, especially in terms of preventable readmissions, are receiving reductions in Medicare reimbursements (Stone & Hoffman, 2010, CMS, 2014). Congestive Heart Failure (CHF) or Heart Failure (HF) is recognized as a primary cause of 30-day hospital readmissions. Causes of HF readmission include inadequate patient education and planning for discharge, inappropriate medication reconciliation, and poor or inadequate follow-up in the days following discharge (Agency for Healthcare Research and Quality (AHRQ), 2009). Thus, many hospitals and facilities have implemented transitional care protocols to help reduce HF 30-day readmissions. Among the geriatric population, HF is a major contributor of morbidity and mortality, and the frail, elderly men and women residing in long-term care (LTC) or skilled nursing facilities (SNF) are particularly prone to the adverse health effects of repeated preventable hospitalizations. The purpose of this project is to provide and promote evidence-based transitional care methods to the nursing staff at a long-term care (LTC) facility in NJ in order to reduce 30-day HF hospital readmissions.

This project’s significance lies in its potential to improve quality of life for the long-term care residents, by reducing the physical and emotional burden of frequent preventable hospitalizations. The conception of the project began with the realization of the lack of evidence-based transitional care practices, due to observed preventable re-hospitalizations within the LTC facility. This led to a thorough literature search, which confirmed the prevalence and incidence of repeated hospitalizations for HF as well as other conditions, and the effects of transitional care. Initiation of the project began with a meeting that was held with the key administrators, presenting the outline and the benefits of the proposed project. After approval was obtained, then educational in-services for the nursing staff, lasting approximately 30-35 minutes, were instituted. A pre- and post-test method was utilized to measure change in knowledge of CHF management. Out of 8 in-services to date, all revealed that education did indeed increase initial nursing knowledge regarding transitional care to reduce 30-day HF readmissions. A similar test should be administered 3-6 months later to measure the long term effects of the education.