Date of Award


Document Type



College of Nursing

Degree Name

Doctor of Nursing Practice (DNP)

Project Mentor

Anita Jablonski


Gira Shah


Purpose: The Hospital Readmission Reduction Program (HRRP) under the Affordable Care Act has been used to incentivize organizations to reduce readmission rates for multiple conditions including Heart Failure (HF). Zone tools (stoplight tools, or action plans) have been used for patient education to promote outpatient management of HF patients. These tools indicate how to monitor symptom changes and what follow-up action needs to be taken by the patient. With increasing blending of technology in healthcare, these tools are now integrated with digital monitoring technologies. This evaluation explores the effect of these technologies on the 30-day and 60-day rehospitalization rates in one home health ministry in Washington State. Staff perceptions on the utility and efficacy of these tools were also measured.

Design: This evaluation used a mix-methods approach. Aggregated data on rehospitalization rates were scrubbed by SPH analytics software at the host agency and provided to the primary investigator for analysis. A survey was sent to staff members containing Likert-scale and open-ended questions. All quantitative data, including Likert-scale questions, were analyzed using descriptive statistics, while qualitative data were analyzed through manual thematic analysis using an inductive method.

Results: Rehospitalization rates were reduced in Ministry 3 by 8.4% and 8.7% for the 30- and 60-day rehospitalization rates, respectively. This ministry is the site with remote digital monitoring. While one other ministry also lowered their 30-day rate, this trend was not sustained into the 60-day rate. About 6% of the total staff across the three ministries responded to the staff survey. While 22 individuals responded, two of them responded “never” to the question of how often they use zone tools in their current practice and were excluded from the evaluation. Most respondents had been at the agency for 10 or less years and most use only the paper version of the zone tools. Of the three respondents who indicated using both paper and digital versions, only one indicated zone tools were slightly more effective. The other two indicated they were not more effective at all.

Discussion: The results from analyzing the rehospitalization shows there was something done differently at Ministry 3 which sustainably lowered the rate, keeping it low beyond the 30-day mark. Further investigation into the factors which contributed to this correlation will help clarify if the remote monitoring program was a success. Due to the low response rate to the staff survey, it is questionable if the perceptions gathered in this evaluation are representative of the entire agency. Furthermore, subsequent studies should consider surveying the patients themselves—the end users—to better understand the utility of these tools.