Date of Graduation

Fall 12-16-2022

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Susan Mortell

Second Advisor

Carla Martin


Problem: Heart failure (HF) is the second leading condition of hospital readmissions. Evidence shows that patient education on self-care and disease management can help reduce and prevent 30-day hospital readmissions. Registered nurse case managers (RN CMs) can help improve patients' ability to self-manage their condition and prevent 30-day hospital readmissions by applying a standard approach to patient education.

Context: The Integrated Care Management (ICM) is an outpatient department that provides post-discharge patient calls. The ICM RN CMs utilized various HF patient education tools for patient teaching. The organization’s HF task force developed health-literate patient resources to be used uniformly across the system.

Intervention: RN CMs will be trained on standardized HF resources. All HF patients eligible for ICM services recently discharged from the hospital will receive the newly standardized HF education from the RN CM.

Measure: The targeted outcome is reducing the 30-day hospital readmission rate for HF patients by 2.3%. The process measure is to achieve 100% utilization of a documentation template applied to all HF patients receiving HF education.

Results: There were no HF readmissions within the project time frame, thus achieving the target reduction of 2.3% for the 30-day HF hospital readmission rate from 11.9% to 9.6% %.

Conclusions: Standardized HF patient education tools and documentation templates can streamline the management of HF patients after discharge from the hospital and reduce 30-day readmissions in this patient population.

Keywords: heart failure, patient education, 30-day hospital readmissions

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