Date of Submission

Spring 5-4-2022

Document Type


Degree Name

Doctor of Nursing Practice (DNP)



First Advisor

Dr. Elena Capella

Second Advisor

Dr. Mary Lynne Knighten


Purpose/Objectives: This review evaluates the published studies on how post-acute care collaboration ensures a continuum of care and reduces heart failure (HF) readmissions.

Primary Practice Setting: An integrated literature review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement. PubMed and Cumulative Index to Nursing and Allied Health were searched for the keywords heart failure AND (post-acute care OR transitional care OR skilled nursing facility OR rehabilitation facility OR home health agency) AND (readmission) AND (care coordination OR collaboration OR interprofessional OR partnerships). Seventy-nine studies were returned, and a reverse reference search yielded four studies. Of those studies, 14 were selected for critical appraisal of evidence. The practice settings of these studies were hospitals, homes, home health agencies, and skilled-nursing facilities.

Findings/ Conclusion: Multidisciplinary management of HF patients, high-impact transitional care interventions, and integration with post-acute care facilities decreased HF 30-day readmissions. Collaborative models involving a skilled HF team, primary care physicians, and post-acute care partners, and targeting post-discharge follow-ups positively impacted outcomes. Bundling interventions, such as home visits, follow-ups (telephone and/or clinic follow-up), and telecare significantly impacted outcomes compared to their delivery in isolation.

Implications for Case Management Practice: Case Management leaders are vital decision-makers and key stakeholders in building the collaboration with community partners. As case management roles extend to outpatient and ambulatory care, better opportunities emerge to coordinate services across settings. Key takeaways for the case management practice is to build a robust case management program spanning post-acute care facilities, evidence-based treatment protocols, and infrastructure that supports seamless information sharing between sites.

Included in

Nursing Commons