1. Running head: IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 1
Impact of Nurse-Led Outpatient Follow-Up Care on Reducing Heart Failure Readmission Rates
Allison Blackburn, Samantha Rabuck, and Jenne Rivera
Alvernia University

2. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 2
Introduction
There are many areas in the healthcare field that need to be addressed to continually
improve care and, therefore, optimize the quality of care. In this case, there is an increasing
problem with heart failure patients. Each year there are at least 825,000 new patients diagnosed
with heart failure (Thomas, Hawkins, Perkins, Hamilton, & Nelson, 2015). The biggest issue is
that the rate of new incidences continues to rise. Since 2006, the number of new diagnosis has
increased from 500,000 new cases, and is classified as one of the major health problems,
especially over the age of sixty-five (Kutzleb & Reiner, 2006). The increase in diagnosed heart
failure patients poses a problem in the healthcare system in which many patients are treated,
discharged, and soon return to the hospital for the same reason. This evidence-based research
focuses on the implementation of additional interventions that can decrease the rate of
readmission and, therefore, decrease cost.
Population
The emphasis of this research focuses on a population that includes recently discharged
heart failure patients. These patients are at high risk for returning to the hospital within thirty
days. Readmission rates are becoming increasingly significant as hospitals are not reimbursed for
patient readmissions that are directly correlated to heart failure exacerbation. In hopes of
reducing readmissions, hospitals are initiating performance expectations and policies, in which
nurses take on a vital role. Optimal nursing care is necessary in delivering best practice in
healthcare, as nurses are primary advocates for the patient and provide individualized teaching.
Intervention
Many organizations agree on the importance of patient education in caring for patients
with heart failure. Continued outpatient teaching and care can significantly reduce readmission

3. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 3
rates as well as costs (Koelling, Johnson, Robert, Cody, & Aaronson, 2004). Outpatient care that
can benefit patient outcomes include telephone follow-ups and nurse-led group educational
sessions in combination with discharge teaching.
Studies have been conducted to demonstrate how nurse-led outpatient follow-up care can
positively affect patient health. Outpatient follow-up care includes the implementation of follow-
up calls within 48-72 hours after discharge and providing continued support beyond this time
frame (Lee & Sunhee, 2010). Nurses must be available to support patients as they transition from
the inpatient to the outpatient setting. Weekly nurse-led group educational sessions can be
another resource for patients and families to continue increasing their knowledge of heart failure.
Comparison
Under normal circumstances, this population receives discharge patient teaching about
the disease process and important self-care interventions, but the issue of readmissions continues
to exist causing continued loss of reimbursements. Healthcare goes beyond the interventions
provided within the inpatient facility. It also includes care of patients outside the hospital
settings.
Outcome
By comparing current practice to an additional intervention such as nurse-led outpatient
follow-up care, research can show if the outcome results in decreased acute care readmission
rates. Overall, there is a need for initiating new evidenced-based practice to reach a favorable
outcome.
Population, Intervention, Comparison, Outcome (PICO) Question
This evidenced-based research seeks to answer the question: In heart failure patients
recently discharged from the hospital, does additional nurse-led outpatient follow-up care,

4. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 4
compared to sole implementation of discharge teaching instructions by registered nurses,
decrease acute care readmission rates?
Significance
The nursing role is significant to patient education in reducing readmissions and costs.
When nurses take on their role as educators, they are able to provide individualized patient
education within and outside of the hospital. Ongoing patient education can positively impact
patient health and significantly reduce mortality when providing the necessary interventions
(Koelling et al., 2004). As educators, nurses can continue with follow-up calls and lead weekly
educational groups to provide an extra resource for patients after discharge and help them to
effectively manage necessary lifestyle changes. Weekly sessions also gives patients a place to
build a support system and promotes compliance of self-care changes. Ongoing telephone
follow-up gives patients the chance to speak one-on-one with the nurse about any concerns they
may have and specific teaching can be continually reinforced.
Effective communication in nursing is also significant to patient education as it promotes
rapport and helps to build a trusting relationship between the nurse and patient. With culturally
sensitive and thorough communication, the patient may be more receptive to self-care teaching.
In order for the nurse to provide effective teaching and improve patient outcomes, they must
have excellent communication skills and understand how to utilize them in their practice.
Current Practice
In the Progressive Care Unit at a local community hospital, current practice involves
discharge teaching specific to the patient with heart failure. Patients are given educational
booklets providing major teaching points necessary post-discharge. This booklet is named as
follows: “Caring for your Heart at Home: Guidelines for Patients with Heart Failure.” Nursing

5. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 5
discharge teaching involves educating the patient on the importance of taking daily weights,
monitoring sodium and fluid intake, medication compliance, and reporting of signs and
symptoms of exacerbation. If the family is available, the nurse also includes them when teaching
the patient.
Evaluation of Evidence
Thorough inpatient teaching provides a foundation for patients to make appropriate
lifestyle modifications in order to successfully manage heart failure at home. A heart failure
educational packet, such as the one provided upon discharge from one local community hospital,
outlines many pertinent points regarding self-care and management of this complex disease. In
addition to providing the heart failure educational packet, nurses are in a vital position to explain
to patients how they can best manage their heart failure at home, and provide insight into what a
heart failure diagnosis means in the context of the patient’s current lifestyle (Kuzleb & Reiner,
2006). Inpatient teaching points that the nurse must emphasize include: what a heart healthy diet
consists of, sodium restrictions that may be in place, the importance of checking food labels, the
proper technique for obtaining and recording daily weights, and the reasoning for strict
compliance with each medication (Smeltzer, Bare, Hinkle, & Cheever, 2010). According to
Albert et al. (2015), building rapport and maintaining a trusting relationship with the patient and
family promotes more successful self-care and management of heart failure. Albert et al. (2015)
and Kuzleb & Reiner (2006) both display evidence that suggests nursing advocacy and
involvement in thorough education and communication yields a positive effect on successful
management of heart failure. Excellent self-care ultimately reduces the likelihood of acute care
readmission.

6. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 6
Potential strategies to improve nurse-patient communication and facilitate rapport may
include active listening skills on behalf of the nurse, including a caregiver or family support
person in the teaching process, providing the patient and family with the nurse’s contact
information, and ongoing communication via telephone once the patient is discharged. Lee &
Park’s (2010) meta-analysis provides level I evidence that suggests telephone-based nurse-led
intervention significantly decreases hospital readmission rates among heart failure patients.
According to Lee & Park (2010), post-discharge telephone contact allows for continued
monitoring of patient symptoms, provides the opportunity for the nurse to reinforce patient
education, and supports open communication between the nurse and patient. Despite the home-
health focus and telemonitoring system approach to Thomason, Hawkins, Perkins, Hamilton, and
Nelson’s (2015) study, the main findings of their article correlate closely to those of both Lee &
Park (2010) and Smith (2013). Each of these studies, ranging from level I to level IV evidence,
propose similar findings in regards to the benefits of post-discharge follow-up telephone contact
in reducing acute care readmission.
To implement this intervention, the nurse is responsible for providing a post-discharge
follow-up telephone call to the patient within two to three days in order to evaluate well-being
and compliance. Each telephone call gives the nurse an opportunity to verbally assess the patient
and detect signs or symptoms of worsening condition (Lee & Park, 2010; Thomason et al., 2015;
Smith, 2013). Early recognition of symptoms allows the nurse to quickly intervene. Furthermore,
the nurse can seek to determine the reason for symptom exacerbation and provide additional
patient education accordingly. Continued telephone contact provides the opportunity for the
nurse to reinforce patient education and serve as a support person in the plan of care (Lee &
Park, 2010; Thomason et al., 2015). The patient learns how to recognize and manage symptoms

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independently when the nurse continually provides patient-specific teaching based on their
assessments and the patient’s subjective symptoms. Nurses are able to hold patients accountable
for management of their heart failure and improve their ability to recognize symptoms of
exacerbation when they require that the patient provide pertinent data, such as a daily weight
(Thomason et al., 2015). Asking patients questions about their current condition facilitates
involvement in self-care, and patients may feel more accountable when they know they will need
to monitor and report data to the nurse each day. Lastly, continued telephone contact provides
patients with the opportunity to ask questions and express concerns regarding home management
of heart failure. The evidence suggests that these benefits of nurse-patient telephone contact post-
discharge result in more successful self-care and management of heart failure, which ultimately
reduces acute care readmission rates.
In addition to telephone follow-up by the nurse post-discharge, weekly nurse-led group
educational sessions are another way to reduce readmission rates for patients who have been
diagnosed with heart failure. This intervention requires nurses to conduct educational sessions at
the hospital each week to reinforce self-care and management techniques. Evidence shows that
patients are more engaged in a group setting because of increased interactions, which has
multiple benefits for patients managing a chronic illness such as heart failure (Slyer & Ferrara,
2013). Slyer and Ferrara (2013) report level I evidence based on a synthesis of randomized
controlled trials, non-randomized controlled trials, quasi-experimental trials, and qualitative
study designs. The level of evidence is a strength of this study; however, the cause of
readmission among heart failure patients attending group educational sessions was not taken into
account. Although this is a limitation for this particular study, both Slyer and Ferrara (2013) and

8. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 8
Koelling, Jonson, Cody, and Aaronson (2005) present evidence that supports a group educational
model in reducing acute care readmission rates in patients with heart failure.
The evidence suggests that patients who attend weekly nurse-led group educational
sessions are more consistent in following a heart failure self-care regimen (Slyer & Ferrara,
2013; Koelling et al., 2005). Increased interaction among group members and the nurse invites
patients to ask questions regarding self-care (Slyer & Ferrara, 2013). This further engages
patients in the management of their condition and promotes a better understanding of self-care
strategies. In general, additional reinforcement of educational content increases the patient’s
knowledge. This same concept applies to patients who are learning to adjust their lifestyle to
manage their heart failure at home. Slyer & Ferrara (2013) report that group visits, as compared
to one-on-one visits with a health care provider, demonstrated increased patient knowledge of
heart failure and self-care abilities. Furthermore, a group visit model has the potential to increase
quality of life. Attending educational sessions with peers who are experiencing the same
condition encourages mutual support, promotes accountability, and results in increased
compliance to a self-care regimen (Slyer & Ferrara, 2013). Peer support also fosters a sense of
belonging and empowerment which may help the patient feel more in control of their condition.
Depression often accompanies chronic health issues due to its effect on quality of life and other
factors such as financial burden. According to Slyer & Ferrara (2013), continuous support from
others who are battling the same condition may combat depression. Similar to telephone contact,
seeing a patient weekly allows the nurse to monitor for exacerbation of symptoms and intervene
as necessary. Not only do patients learn from the educational content the nurse presents, but
patients also benefit from the knowledge and experiences of others (Slyer & Ferrara, 2013).
Nurses must utilize this evidence when educating patients in order to promote a greater

9. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 9
understanding of heart failure and ways in which it can be managed. Techniques supported by
the latest evidence, such as post-discharge telephone contact and nurse-led group educational
sessions, have shown outcomes that include a decrease in readmission rates in heart failure
patients.
Recommendations for Nursing Practice
Based on the positive patient outcomes of telemonitoring and weekly nurse-led
educational sessions, all hospitals should begin implementing these interventions to reduce the
readmission rate of patients diagnosed with heart failure. Telemonitoring allows the nurse to
identify exacerbations of the patient’s condition and resolve the issue before the patient requires
hospitalization. Building rapport with the patient is essential for this type of intervention to be
successful. Strategies to build rapport between the nurse and patient can include active listening
and open communication. Building rapport should begin with the very first encounter between
the nurse and patient, whether this is in the hospital or beginning with the first telephone
conversation after discharge. If applicable, the family should also be involved in the patient’s
care and including them in the teaching also helps to build rapport. Nurses should also provide
the patient and family with contact information to allow them to call the nurse if they have any
questions regarding the management of their heart failure. Building rapport with a patient allows
for open communication between the nurse and patient, resulting in increased compliance and
better outcomes.
To have the most successful outcomes with telemonitoring, the nurse should inform the
patient on the information that is required during each telephone call, such as a record of daily
weights. Appropriate assessment questions should be asked so the nurse is able to determine if
the patient is being compliant with their treatment regimen. The nurse will also be able to assess

10. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 10
if the patient is having an exacerbation of their heart failure and can respond appropriately.
During each telephone call, the nurse should emphasize one educational point that was discussed
during the conversation to encourage the patient’s learning. Telemonitoring allows the patient to
have direct contact with the nurse and should be given the opportunity to ask any questions or
discuss any concerns that they have. With open communication between the nurse and patient
through telephone calls, the patient is able to better manage their condition, which improves their
outcomes.
Hospitals should also organize a weekly nurse-led educational session and encourage all
heart failure patients to attend. Health care providers should discuss the benefits of these
sessions, such as increased knowledge of self-care techniques and management of their heart
failure, which will improve their quality of life. Participating in these weekly educational
sessions can allow the patients to support each other and hold each other accountable for the
management of their condition. Having the continuous support from others with the same
condition can help a patient feel empowered. Peer support may encourage feelings of being in
control of their condition, and may help to combat depression that often accompanies chronic
disease. Weekly nurse-led education sessions help the patients to become more involved in the
management of their heart failure and are shown to improve patient outcomes making it
extremely beneficial for hospitals to begin implementing them.
Conclusion
Heart failure is one of the most common diagnoses for people over the age of sixty-five,
and each year there are at least 825,000 new patients diagnosed (Thomas et al., 2015). High
readmission rates are a major problem with this condition, which is why this evidence-based
research focuses on strategies to reduce readmission rates. Two interventions shown to reduce

11. IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 11
readmission rates for heart failure patients include outpatient follow-up telemonitoring and
weekly nurse-led educational sessions. Both of these interventions promote patient education and
allow the patients to manage their condition, improve their health, and reduce the risk of being
readmitted to the hospital for an exacerbation.

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