Running head: PLANNING STAGE 2-(DESIGN PHASE) OF A RESEARCH PROJECT 1 PLANNING STAGE 2- (DESIGN PHASE) OF A RESEARCH PROJECT 8 Planning Stage 2- (Design Phase) of a Research Project Student name Florida National University Planning Stage 2- (Design Phase) of a Research Project Heart failure is one of the most common types of chronic conditions among the elderly, which results into increased readmissions globally. This statistic is attributable to poor coordination and communication in the transition care settings. The various care settings include skilled nursing facilities, acute-care hospitals, long-standing care facilities and ambulatory stay (Naylor et al., 2017). This research paper is aimed at investigating the reason for poor continuity of care in transition care facilities. A detailed literature review was performed regarding the standard of care in such settings for patients with heart failure. The research methodologies used include case study methods, interviews, and administration of questionnaires. Probability and non-probability methods including stratified sampling and convenience sampling were used as the sampling methodologies. The necessary tools for data collection include questionnaires, interviews, schedules and observation techniques. In addition, an algorithm was created during this design phase. Thus, an insight into the design phase is sought and discussed herein. Literature Review Heart failure is a prolonged condition that has been highlighted as one of the top causes of public health complications in the world. The American Journal of Accountable care provides detailed information on heart failure as a public health problem. According to this journal, there are numerous causes of readmission of patients undergoing the transition care model (A Literature Review of Heart Failure Transitional Care Interventions, 2019). The journal highlights various issues, such as early discharge, poor management of underlying problems, poor coordination among key stakeholders and early discharge of patients as the major causes of readmission. All such issues can, however, be prevented and thus this research will discuss some of the coping methods. In addition, the US medical beneficiaries discuss the quality and safety in the transition care model (Teno et al. , 2018). Some of the beneficiaries state their experiences following being admitted into the transition care model. This article complements the previous article by adding real life case study analysis of patients who have been previously admitted to the transition care. Further, interviews of clinicians working in the transition care model are highlighted with an explanation of failure to conduct follow up visits of particular patients. The American Journal of Public Health explores the affordability of the transition care and the quality of care that some patients can be able to afford. The article has explored the ...

1. Running head: PLANNING STAGE 2-(DESIGN PHASE) OF A
RESEARCH PROJECT 1
PLANNING STAGE 2- (DESIGN PHASE) OF A RESEARCH
PROJECT 8
Planning Stage 2- (Design Phase) of a Research Project
Student name
Florida National University
Planning Stage 2- (Design Phase) of a Research Project
Heart failure is one of the most common types of chronic
conditions among the elderly, which results into increased
readmissions globally. This statistic is attributable to poor
coordination and communication in the transition care settings.
The various care settings include skilled nursing facilities,
acute-care hospitals, long-standing care facilities and
ambulatory stay (Naylor et al., 2017). This research paper is
aimed at investigating the reason for poor continuity of care in
transition care facilities. A detailed literature review was
performed regarding the standard of care in such settings for
patients with heart failure. The research methodologies used
include case study methods, interviews, and administration of

2. questionnaires. Probability and non-probability methods
including stratified sampling and convenience sampling were
used as the sampling methodologies. The necessary tools for
data collection include questionnaires, interviews, schedules
and observation techniques. In addition, an algorithm was
created during this design phase. Thus, an insight into the
design phase is sought and discussed herein.
Literature Review
Heart failure is a prolonged condition that has been highlighted
as one of the top causes of public health complications in the
world. The American Journal of Accountable care provides
detailed information on heart failure as a public health problem.
According to this journal, there are numerous causes of
readmission of patients undergoing the transition care model (A
Literature Review of Heart Failure Transitional Care
Interventions, 2019). The journal highlights various issues, such
as early discharge, poor management of underlying problems,
poor coordination among key stakeholders and early discharge
of patients as the major causes of readmission. All such issues
can, however, be prevented and thus this research will discuss
some of the coping methods. In addition, the US medical
beneficiaries discuss the quality and safety in the transition care
model (Teno et al. , 2018). Some of the beneficiaries state their
experiences following being admitted into the transition care
model. This article complements the previous article by adding
real life case study analysis of patients who have been
previously admitted to the transition care. Further, interviews of
clinicians working in the transition care model are highlighted
with an explanation of failure to conduct follow up visits of
particular patients.
The American Journal of Public Health explores the
affordability of the transition care and the quality of care that
some patients can be able to afford. The article has explored the
different forms of care based on affordability from the cheapest
to the most expensive (Hirschman et al., 2015). This research
has shown that since most patients are not able to afford the

3. premium packages, they acquiring poor quality of care. A
randomized clinical trial has also been conducted testing patient
home based care (Adepoju et al. , 2015). This study involved
collecting data and observing willing patients who were
undergoing the transition care model and writing down their
experiences. Given such an extensive research, the study has
filled in the gaps of the previous articles in that the patients
were keenly observed and all their experiences duly registered.
Thus, these articles form a basis for this research project for
they provide the researchers with a founding ground of
conducting their research.
Methodology and Design of the Study
The research methods used in this study include case studies,
interviews, as well as questionnaires. The case study entails an
analysis of patients who were undergoing the transition care
model. The selected patients must be willing to participate in
the study and provide accurate feedback on their progress. The
case study will be undertaken within the period of the admission
of the patient into the hospital to determine their experiences
when they are subjected to the transition care model and
whether they are readmitted to hospital or released to
ambulatory stay. During the case study, detailed interviews and
observations of the patients willing to take part in the research
can be conducted. A longitudinal study can be conducted where
the patients undergoing the transition care model are observed
throughout the process. Such an approach is beneficial for
research purposes and can be used as a research methodology
for the research project.
Interviews are also an important form of research methodology
that can be used. The researcher will conduct interviews with
everyone who is affected by the transition care system including
the patients, their care takers, family, as well as the clinicians
and the nurses. The reasons for poor continuity of care include
lack of follow ups from the physicians and therefore it is
important to interview them and establish the reason for such
behaviour. Additionally, most family members and care givers

4. lack the necessary information regarding the best forms of care
for their patients, which makes them an important part of data
collection (Adepoju et al. , 2015). The patients can be
interviewed and allowed to express their thoughts regarding the
possible improvements. Additionally, questionnaires can be
administered to the same group of individuals. These
questionnaires allow individuals to express their genuine
opinions privately by answering multiple choice questions,
closed questions, and open ended questions. Thus,
questionnaires and interviews are a critical aspect of the
methodology of the research.
Sampling Methodology
The sampling methodology for this research will entail both the
probability sampling and the non-probability sampling methods.
In the probability sampling method, stratified sampling can be
employed. This approach will involve dividing the group of
people for the study into subgroups that share common
interests. All physicians and nurses for instance could be placed
into one group whereas the patients and their care givers could
belong to another group. The study can also be done in three
different settings where results will be compared for patients
from one hospital to those from another hospital. This form of
sampling is important for it ensures accurate estimation of
health outcomes in the transition care setting. Such a projected
result can be attributed to the increased representation, which in
turn reduces sampling biases. Non-probability sampling will
also be a key feature of sampling method for this research. In
this case, convenience sampling will be used, which entails
selecting participants based on their willingness to cooperate
and their availability for the study. Thus, stratified and
convenience sampling are the two important sampling methods
that can be used for this research.
Necessary Tools
The necessary tools for the research include questionnaires,
interviews, schedules, and observations for data collection. The
questionnaires deal with significant and important topics which

5. are carefully stated, complete, short and clear. Interviews are
the most important tools for they provide flexibility during the
research phase. They can be adjusted to suit the population
being interview and therefore improve the chances of collecting
accurate data. The interviews allow for deep and direct
research, examination of the known information and exploring
past and future information. Schedules can be used as necessary
tools for data collection where researcher questionnaires can be
used for interview purposes. This approach increases the
percentage of responses, makes it possible to observe other
factors and any defects can be detected and corrected
immediately. On the other hand, observations will serve an
expressed research purpose. They are methodically planned, and
require employment of personal skills and can be administered
formally and informally. Thus, these tools are important for
they will ensure necessary data collection.
Algorithms and Flow Maps Created
Various algorithms for the research were created in order to
help the researcher to follow a systematic form during the
study. The flow maps summarise the steps of investigation and
highlight the important aspects of the study.
(
Screening
H
eart failure patients
medical records
Co
nfirm eligibility through communication
with ph
ysicians and also
obtain written
referral
s
)

6. (
Enro
l
ment
Invite
study participants who are heart failure
patients
I
nformed consent form
should
be signed
Obtain demographic data baseline (quality of life, symptom
intensity
,
and
function
al status)
)
(
Randomization
to enhance data representation of entire population
)
(

7. Usual
care systems
) (
Usual
care plus transferred into the transition care model
)
(
Outcome
measures
quarterly within a period of a year
post enrolment
Readmission rate
Quality of life
Symptom intensity
Functional status
Satisfaction of care
)
Conclusion
In conclusion, the design phase is focused on conducting a
detailed research regarding the care for patients with heart
failure in the transition care settings. A thorough literature
research has been conducted regarding transition care model and
the continuity of care being offered in these setups. Most of the
causes of readmission in hospitals can be avoided if some
changes are implemented in the care plan of these patients. The
methodology and design of this research will be comprised of
case study methods, interviews, and administration of
questionnaires. The sampling methodology will involve the
procedure of subdividing the interested parties into subgroups

8. for accuracy and efficiency. The necessary tools for data
collection and analysis have also been highlighted including
interviews, schedule completions, questionnaires and
observations. Various flow charts for the study have been
developed to ensure the study is conducted in a systematic
manner and that all aspects of the study have been considered.
Thus, the design phase of this research project has been
discussed and analysed in this paper.
References
A Literature Review of Heart Failure Transitional Care
Interventions. (2019). AJMC. Retrieved from
https://www.ajmc.com/journals/ajac/2017/2017-vol5-n3/a-
literature-review-of-heart-failure-transitional-care-
interventions.
Adepoju, O. E., Preston, M. A., & Gonzales, G. (2015). Health
care disparities in the post–Affordable Care Act era. American
Journal of Public Health, 105(S5), S665-S667.
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., &
Naylor, M. D. (2015). Continuity of care: The transitional care
model. Online J Issues Nurs, 20(3), 17-32.
Naylor, M. D., Hirschman, K. B., Hanlon, A., Barg, R.,
McCauley, K., Shaid, E., & Pauly, M. (2017). Testing the
patient-centered medical home plus transitional care model.
Innovation in aging, 764-764.
Teno, J. M., Gozalo, P., Trivedi, A. N., Bunker, J., Lima, J.,
Ogarek, J., & Mor, V. (2018). Site of death, place of care, and
health care transitions among US Medicare beneficiaries, 2000-
2015. Jama, 320(3), 264-271.