Date of Award
Spring 5-22-2025
Document Type
Doctor of Nursing Practice Final Manuscript
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Lilian Chan, DNP, RN, PCCN
Abstract
Abstract
Background: Heart failure (HF) is a chronic, progressive condition and a leading cause of hospital admissions nationwide. The 30-day readmission rate for HF patients is approximately 23.4%, contributing to increased morbidity, mortality, and significant healthcare costs. Each HF-related readmission is estimated to result in a financial loss of $15,789 per patient due to reduced reimbursement from both private and public insurers. This underscores the critical need for timely follow-up care, particularly within the first 30 days post-discharge.Without adequate follow-up and patient education, many individuals lack the confidence and knowledge necessary for safe and effective self-management in the outpatient setting, increasing the risk of preventable readmissions.
Purpose of Project: This evidence-based project implemented structured telephonic follow-ups for HF patients at 48–72 hours, two weeks, and four weeks post-hospital discharge. Patients completed the Self-Care Heart Failure Index (SCHFI) 7.2 before and after the intervention to assess changes in their HF self-care knowledge. Each follow-up included screening for signs of decompensation and tailored education on recognizing early warning signs to enhance patient self-management.
EBP Model/Frameworks: This evidence-based project was designed based on the Stetler Model of Evidence-Based Practice. This framework provides a step-by-step process for synthesizing data and implementing this project safely and effectively.
Evidence-Based Interventions/Benchmark: Between June 1, 2024, and November 1, 2024, this project implemented a structured telephonic follow-up protocol for HF patients, with scheduled calls at 48–72 hours, two weeks, and four weeks post-discharge. These follow-ups enabled clinicians to provide comprehensive patient education on self-care management, monitor for signs of decompensation, and address concerns proactively. The Self-Care Heart Failure Index (SCHFI) 7.2 was used to evaluate patients’ confidence in managing HF symptoms across three domains: self-maintenance, symptom perception, and self-management. A score of ≥70% in each domain indicated adequate HF self-care.
Evaluation of Results: A total of 30 patients were enrolled; 12 were lost to follow-up. Among the 18 who completed the intervention, 3 were readmitted within 30 days, yielding a 16.6% readmission rate—a 6.8% reduction compared to the national average. Post-intervention SCHFI 7.2 scores showed improvements across all three domains: self-care maintenance (+5.89%, p < 0.0003), symptom perception (+6.37%, p < 0.0004), and self-care management (+6.11%, p < 0.0001), indicating enhanced confidence in managing HF symptoms at home. While the intervention led to a reduction in readmissions, this was not statistically significant (p = 0.4441).
Implications for Practice: Structured follow-up at 48–72 hours, two weeks, and four weeks post-discharge can reduce hospital readmissions and enhance patients' confidence in managing HF. Ongoing education at multiple time points improves self-care capabilities and disease management. This project reinforces the importance of early, structured follow-up in tertiary care to prevent morbidity and mortality in HF patients.
Conclusions: Future evidence-based projects should explore additional aspects of HF management in outpatient settings, including patient and provider satisfaction with the current follow-up process. Expanding interventions to include digital health solutions and multidisciplinary approaches may further optimize patient outcomes.
Keywords: heart failure, telephonic follow-up, structured follow-up, patient education, self-care heart failure index (SCHFI) 7.2
Digital USD Citation
Carroll, Kelly, "Improving Patients' Confidence in Self-Care Management and Preventing Hospital Readmission Within 30 Days of Discharge in the Heart Failure Population" (2025). Doctor of Nursing Practice Final Manuscripts. 294.
https://digital.sandiego.edu/dnp/294
Copyright
Copyright held by the author
