Date of Graduation

Spring 5-18-2023

Document Type


Degree Name

Doctor of Nursing Practice (DNP)


School of Nursing and Health Professions




Family Nurse Practitioner

First Advisor

Jo Loomis

Second Advisor

Maria Cogan


Heart Failure (HF) is a difficult disease to manage. It requires knowledge on weight monitoring, diet, exercise, medications, and symptom management. With this difficulty, there is a high incidence of HF patient readmissions into the hospital, especially in the first 30-days after discharge, showing that patients are not well equipped to manage their HF on their own at home. A review of the available literature found that some of the most common reasons for readmission include poor discharge planning, a lack of continuation of care, as well as a lack of education and adherence to their medications (Mathew & Thukha, 2018). Studies also found that implementing outpatient education can help to decrease the number of 30-day readmissions for HF patients (Blum & Gottlieb, 2014).

A Doctor of Nursing Practice (DNP) student-led quality improvement project focused on decreasing 30-day HF hospital readmissions was implemented using telehealth education and screening for patients recently discharged. Patients received four phone calls, one per week for four weeks, received education on management of their HF (medications, daily weights, diet, etc.) and were screened for symptoms and to see how they were doing outside of the hospital. The largest potential benefit of this program is reducing 30-day hospital readmissions, as it targets patients when they are recently discharged, which is their most vulnerable time. Other potential benefits include a higher quality of life, decreased morbidity and mortality, and large cost savings for the hospital. The potential benefits of this project depend upon buy-in from a hospital and full participation from patients. Limitations include a lack of participation from patients, lack of buy-in from a hospital and their staff, and patients not completing the full four weeks of telehealth visits. This project has limited overhead costs and risks, and a large potential for successfully reducing 30-day hospital readmissions.