Date of Degree

Summer 2025

Document Type

DNP Scholarly Project

Academic Department

School of Nursing

Degree Type

Doctoral

Degree Name

Doctor of Nursing Practice

First Advisor

Dr. Melanie Brewer

Second Advisor

Dr. Sandra Cleveland

Abstract

Problem: Congestive Heart Failure (CHF) continues to be a prevalent and challenging health issue, contributing significantly to hospital readmissions within the first 30 days of patients transitioning to home health care. Rehospitalization affects the patient's quality of life and the agency's revenue, as reimbursements are paused when patients are hospitalized during the first 30 days of admission to a home health agency. The agency experienced a 22% rehospitalization rate within a year, slightly higher than the national average of 10%.

Aim of the Project: The primary objective of this project was to decrease rehospitalization of patients with CHF within the first 30 days of admission to a home health agency.

Review of the Evidence: A comprehensive literature review identified using a discharge checklist tool within a transitional care team model as effective in preventing rehospitalization of patients with CHF.

Project Design: This quality improvement (QI) project used the Plan-Do-Study-Act (PDSA) Model for Improvement. Additionally, tools from the OhioHealth Change Management Model helped guide the change process, supporting both the development and execution of the project.

Intervention: The intervention was forming a transitional care team that utilized the discharge tool checklist upon admission to the home health agency. All the patients with CHF admitted to the agency during the 10 weeks were enrolled in the program for 30 days.

Significant Findings/Outcomes: 9 patients were enrolled in the program, and there was no rehospitalization of any CHF patients enrolled in the program. Patient satisfaction also improved, and revenue for the agency increased. This signifies that the transitional care team is a proven tool for preventing rehospitalization of patients with CHF within 30 days of admission to home health.

Implications for Nursing: This quality improvement project has demonstrated that an advanced-practice nurse-led transitional care team with interprofessional collaboration is highly effective in reducing rehospitalizations and healthcare costs and enhancing patient outcomes. Integrating and expanding specialized nursing roles in post-acute care, such as home health, increases evidence-based practice and improves the quality of patient healthcare. The project aligns with the Institute of Medicine’s six effective, patient-centered, and timely care domains. It supports the Institute for Healthcare Improvement Triple Aim by reducing readmissions, promoting patient satisfaction, self-care ability, quality of care, and optimizing agency revenue.

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