Date of Graduation

Fall 12-11-2020

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Executive Leader DNP

First Advisor

Dr. Elena Capella

Second Advisor

Dr. Jonalyn Wallace


Problem: Heart failure (HF) is a chronic disease where the heart cannot deliver an adequate amount of blood that the body requires. HF is one of the costliest cardiovascular diseases plaguing public health in the United States (Go et al., 2014). HF is the main reason for hospitalizations in adults and a leading contributor to the rise in healthcare costs. Approximately 25% of Medicare patients are readmitted within 30-days of discharge (Go et al., 2013). To address excessive hospital readmissions, the Centers for Medicare and Medicaid Services (2019) initiated the Hospital Readmissions Reduction Program in October 2012 to reduce Medicare payments to healthcare organizations for unnecessary HF readmissions.

Context: A large academic medical institution specializing in cardiovascular patient-centered care is committed to improving the quality and patient health outcomes among the HF population. This institution is a public healthcare system in Southern California, with multiple campuses collectively operating as one entity. The practicum site operates as a licensed 799-bed facility and is the first comprehensive cardiovascular center in San Diego, California. The site employs approximately 9,100 individuals, consisting of 2,600 medical doctors (students, residents, and fellows) and over 2,500 registered nurses (RN).

Intervention: Case management (CM) coordinates healthcare services for patients to ensure the delivery of cost-effective care (Gray, White, & Brooks, 2013). Interprofessional (IP) collaboration is important to ensure that HF transitional care services are arranged prior to discharge to prevent avoidable readmissions. An IP approach consists of healthcare professionals from different disciplines, with specific knowledge and skills, working collaboratively to enhance the well-being of the individual through patient-centered practice (Allen, Penn, & Nora, 2006). Novice nurses are integral team members, but they often lack CM knowledge and are inexperienced with nurse case manager (NCM) engagement to initiate early discharge planning. Novice nurses are newly-licensed RNs that possess 6 months or less of clinical nursing experience. Cardiovascular novice nurses received a live CM education lecture course to increase awareness of CM and to enhance confidence in NCM collaboration on HF discharge planning to decrease 30-day readmissions.

Measures: The outcome measures for novice nurses to achieve were (a) to enhance knowledge of CM, (b) to increase the confidence level of early collaboration with the NCM, and (c) to reduce 30-day HF readmissions by 10% at 4 months post-intervention. Improving current CM processes by offering novice nurses education to better their understanding of the purpose of CM and the importance of initial collaboration on transitional care planning led to positive outcomes. HF 30-day readmissions were monitored pre- and post-intervention to detect if there was a relationship between novice nurse knowledge of CM and hospital readmissions.

Results: Seventy-five percent of the cardiovascular novice nurses’ who participated in the CM education program self-reported that they possessed no knowledge of the NCM role and had modest confidence in early NCM collaboration. Thirty-eight percent of participants stated they were aware that an effective and safe transitional care plan should be established prior to discharge for HF patients. Participant scores increased by 33% after the NCM education intervention. The Wilcoxon Matched-Pairs Signed Rank Test revealed a significant difference in the novice nurses’ HF CM knowledge scores between pre-education and post-education, N = 7, z = 2.37, p = .018. Furthermore, a 12% reduction in HF 30-day readmissions was observed, based on the enhanced collaboration among the IP team to successfully secure a safe transitional care plan.

Conclusions: HF readmissions remain a domestic concern and greatly impacts healthcare expenditures among adults. Evidence illustrates that an IP approach on transitional care planning for HF patient population reduces 30-day hospital readmissions. Understanding the importance of the NCM role and early IP collaboration to coordinate transitional care services for HF patients yield to favorable patient health outcomes. Although other IP disciplines were excluded from the intervention, future participation in the CM education program would greatly benefit this group. Implementation of a live CM education program for novice nurses demonstrated to be an effective intervention and financially profitable to decrease readmissions by increasing knowledge of the NCM role and development of IP relationships.

Included in

Nursing Commons