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, FNP-BC, GNP, FAANP, Faculty Chairperson

Second Advisor

Kathy James, DNSc, APRN, FAAN, Seminar Faculty

Third Advisor

Karen Macauley, PhD, DNP, MSN


Background: According to the American Heart Association, there are over 5 million people in the United States with heart failure (HF) and projections suggest the prevalence of HF will increase by 46% through 2030. HF is the most common cause of hospital admissions in the United States for patients age 65 years or older and despite improvement outcomes, national readmission rates remain high at 23%. Current guidelines recommend health professionals provide comprehensive HF education and counseling that is not only focused on knowledge, but also on skills of management and self-care behaviors. In order to achieve quality patient-centered care, the patient must actively participate in their plan of care. According to the evidence, self-care management programs in HF can improve self-care and decrease HF readmission and mortality rates

Purpose: The purpose of this evidence-based practice project was to incorporate a HF self-care management program in an outpatient cardiology clinic to improve self-care behaviors and reduce hospital readmissions in HF patients recently discharged from the hospital.

Practice Change: An evidence-based HF self-care management educational program led by an advanced practice-nursing student was implemented in an outpatient advanced HF clinic post hospital discharge. The program included an initial evaluation of self-care using a validated questionnaire, HF self-care education, 5 weekly telephone support calls, and reevaluation of self-care following the program.

Results: Participants had statistically significant improvements in HF self-care maintenance, management, and confidence. The participants had no all-cause 30-day readmissions while 60 and 90-day readmission rates remained below 30%. This program also helped decrease HF all-cause 30-day readmissions to 15.7%.

Implications: The findings from this project suggest that evidence-based outpatient self-care management programs can improve HF patient self-care and reduce readmission rates. This program supports the need for individualized HF outpatient self-care management programs that are designed and supported by advanced practice nurses and registered nurses to reduce readmissions and improve self-care behavior in patients with HF.