Date of Award

Spring 5-26-2018

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice



First Advisor

Scot Nolan, DNP, RN, CNS, CCRN

Second Advisor

Teri Armour -Burton, PhD, CNML, NE-BC

Third Advisor

Colleen Austel Nadeau, BSN, RN, CHFN


Background: In the United States an estimated 5.7 million adults have heart failure (HF), costing $30.7 billion annually. National HF readmission rates have remained high at 21.3%. After an extensive literature review, the purpose of this project was to incorporate teach back methods, self care education, resource accessibility, and increased post-discharge contact through an outpatient heart failure transitions of care program.

Methods and Results: Prior to discharge, HF patients were recruited and given a pre-test Self Care of Heart Failure Index (SCHFI). A DNP student and progressive care unit registered nurses provided discharge education utilizing a Healthy Heart Tracker booklet that focuses on medication adherence, symptom identification, low sodium diet, physical activity, and available resources. The patient was seen at the Heart Resource Center one-week post-discharge for a one-hour education session. During weeks two through four the patient received one telephone follow-up call per week. The program finished with a one-hour HRC visit that provided a summation of education and post-test SCHFI. Pre and post values for both the SCHFI and HF readmission rates were utilized to evaluate the practice change. The total SCHFI score before and after the intervention showed an average 41-point improvement, achieving the project goal of 10% increase in each section. The study readmission rate was 7%, achieving the 14.2% or less target goal and outperforming the hospital readmission rate of 15%.

Conclusions: Outpatient HF programs is critical for increased provider and patient contact to allow for patient empowerment through self-care, barrier identification, and support team development. Standardized discharge with telephonic support may bridge the gap via coaching.


Correspondence to this manuscript should be addressed to Katherine Nicole O. Padiernos, BSN, RN, DNP student


Included in

Nursing Commons