Date of Award


Document Type



College of Nursing

Degree Name

Doctor of Nursing Practice (DNP)

Project Mentor

Benjamin Miller


Diane Fuller Switzer


Heart failure is a chronic collection of symptoms which primarily affect the elderly. The condition requires complex care and management, which is not only taxing on the patient but amass to large costs primarily from hospital admissions and readmissions. Readmissions are a key measurement in heart failure as Centers for Medicare and Medicaid with the Hospital Readmissions Reduction Program has enacted penalties to organizations with excess readmissions. Transitional care is a collection of interventions targeted at preventing readmissions and improving patient outcomes by early intervention and management after a patient has been hospitalized. This project established a pilot transitional care program for a community-basedhealthcare organization with an inpatient and outpatient network. Patients in the transitional care interventions had a lower rate of readmissions compared to previous historical data and those not enrolled in the program, indicating that while a transitional care program requires an increase in resources the benefits have the potential to outweigh the effort. Further studies with a larger intervention group are recommended to further evaluate the effect on heart failure readmissions.

Included in

Nursing Commons