Advanced Practice Registered Nurse – Led Transition of Care for Congestive Heart Failure Patients

Purpose: This scholarly project was to determine if an advanced practice registered nurse (APRN) – led transition of care (TOC) would positively influence the outcome of quality of life in congestive heart failure (CHF) patients. The purpose was to meet Medicare-mandated target goals in reducing readmission to 12%. The project investigates the gap between the time of discharge and transition of care. The improvement plan objectives are threefold: to increase retention of self-care activities utilizing the teach-back method while monitoring emergency room (ER) utilization and measuring benchmark assessment. This project aligns with one of the Institute of Medicine [IOM] six dimensions of patient-centered care. Findings: In the period of February 22 – March 22, 2018, ten subjects were enrolled in the project (N=10). Even though chi square analysis revealed no significant difference (x2 (1, N= 10) = 2.3746, p = .1233) in readmissions post intervention (See Appendix -T); APRN – led TOC demonstrated positive changes in teach back and reteach via leadership competences and clinical experience revealing overall improvement in trends. Discussion: There were ten participants in the pilot study (N=10). Out of these ten CHF patients one was readmitted in the 30-day period of the study. All subjects were carefully followed and monitored. Field assessment benchmark revealed that at one week 100% of all patients were retaining 90% or more of the self-care activities and maintaining appropriate priority tasks. There was no ER utilization and patients in the “yellow” zone knew what to do with a three-pound weight gain.