Date of Award

Spring 5-23-2015

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Shelley Hawkins, PhD., APRN-BC, FAANP

Second Advisor

Heather Adams, DNP, MSN, CNS-BC-CMSRN



Purpose: The purpose of this evidenced based practice project was to evaluate the effectiveness of discharge follow-up calls for heart failure (HF) patients recently discharged from a private hospital.

Background: HF is the number one discharge diagnosis among patients 65 years and older. It affects 5.8 million people in the United States. HF admissions total (1) million annually, however, 24% of these patients are readmitted within 30 days of discharge. Re-hospitalizations are associated with high mortality rates and expenditures approximated at $13,000 per patient contributing to the overall annual expenditure of $33.7 billion. In 2012, the Centers for Medicare and Medicaid (CMS) initiated the Hospital Readmission Reduction Program (HRRP) where excessive all cause 30-day readmissions would be accessed a penalty.

Practice Change: HF patients recently discharged were identified. Using a HF callback form, patients were contacted post-discharge at 24-48H, day 10-15, day 20-25, and day 30-31. During each call, data collection focused on clinical measurements including daily weight, patient reports of symptoms of HF exacerbation, as well as education reinforcement pertaining to diet modification and medication compliance.

Results: Outcomes included 1 of 13 study participants were readmitted within 30 days of discharge, a 7.7% readmission rate. In contrast, those participants who were not included in the practice change experienced a 30-day readmission rate of 17% (10 out of 58).

Conclusion/Implications: This intervention should be explored as standard procedure in similar settings. Outcomes resulted in more effective patient self-care management coupled with a reduction in readmissions.