Date of Graduation

Spring 5-18-2023

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. Mary Lynne Knighten



Background: Heart failure (HF) patients have a high risk of rehospitalization after discharge from acute care. Post-discharge management of HF patients requires coordinating services outside the hospital, such as skilled nursing and home health care to address patients’ complex needs.

Local Problem. High HF readmission rates negatively impact a hospital’s efficiency and pose a risk of financial penalties. In the project setting, the HF patients discharged to skilled nursing facilities and home health agencies had a higher rate of 30-day readmission than patients discharged to home.

Methods: Fourteen post-acute care (PAC) facilities were selected for the interventions. The medical center and 14 PACs collaborated to build a pathway based on the Coordination Networks Multi-Level Framework. The 30-day all-cause readmission rate of the participating PACs was compared pre- and post-intervention.

Interventions: An evidence-based HF Continuum of Care pathway was implemented with six key interventions: HF patient identification during the transition, discharge handoff optimization, post-discharge follow-up, information sharing, inter-organization feedback, and enhancement of nursing knowledge on transitions of care.

Results: Post-implementation, the 30-day readmission rate decreased from 25% to 20% (n=50, p= .466); the completion rate for follow-up phone calls within 48 hours of discharge increased from 90% to 96% (p= .208); discharge appointments were made within ten days for 72% of patients HF transitions of care knowledge assessment of cardiology nurses increased to 4.5% post-education (84.4%) compared to the pre-education (80.8%) (p=.578).

Conclusions: In heart failure patients, post-acute care collaboration using a continuum of care pathway reduced the 30-day readmission rate of patients discharged to partnered PACs.

Key Words: Collaborative care, continuum of care, coordination of care, heart failure, multi-level framework, readmission rate, transitions of care, pathway