Date of Award

Spring 5-22-2021

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor



Background: Heart failure is a leading cause of morbidity and mortality in the United States and accounts for a vast number of 30-day hospital readmissions. Within the first 30 days of discharge, patients and caregivers often misinterpret discharge instructions or lack access to providers. During this period, some modifiable symptoms become too difficult to tolerate and patients return to the emergency department for assessment and ultimately readmission for high-risk complications. The Sars-CoV-2 pandemic has added additional barriers for patients to receive care after a hospital discharge.

Purpose: To identify current best practices used for outpatient follow up with this patient population, develop a standardized intervention project for an advanced practice registered nurse (APRN) to use with heart failure patients, and make recommendations on how to implement the process within their practice.

Evidenced-based Intervention: A three-phase APRN intervention: (a) chart review of hospital course, disposition, and assessment of telemedicine follow up barriers, (b) a telehealth assessment within 1 week of discharge using a heart failure outpatient clinic telephonic consulting questionnaire to assess for progress or deterioration, and (c) a final 4-week assessment using the heart failure questionnaire to review progress and assess readiness for cardiac rehab enrollment.

Implications for Practice: Optimizing modifiable symptoms is paramount to successfully transitioning home from the hospital. Utilizing best practice will optimize modifiable symptoms for a successful transition home from the hospital by increasing access to care, exposure to frequent education and awareness to disease thus moving towards the goal of reducing hospital readmissions.

Keywords: heart failure, transitions of care, telemedicine, advanced practice registered nurse, pandemic

Included in

Nursing Commons