Transitional Care for Patients With Congestive Heart Failure

Transitional Care for Patients With Congestive Heart Failure

Patients with congestive heart failure (CHF) often have to be readmitted to the hospital after being treated. This issue puts patients’ health at risk and destabilizes hospitals, forcing them to distribute additional resources and staff to care for returning clients. To resolve this problem, organizations can implement an early discharge planning initiative that will instruct patients upon leaving the hospital. The project will have such steps as data gathering, analysis, translation into practice, and evaluation of outcomes.

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Change Model Overview

The ACE Star model can serve as a central approach to implementing change in a healthcare setting. It is useful in this sphere because it focuses on evidence-based practices (EBP) and reliable findings. This model consists of five major steps:

  1. “Discovery” – Data gathering;
  2. “Evidence Summary” – Analysis of all related findings;
  3. “Translation into Guidelines” – Formulation of policies that facilitate change;
  4. “Integration into Practice” – Introduction of new processes to the staff;
  5. “Evaluation of Process and Outcome” – Feedback and analysis (Stevens, 2013, para. 14).

The Scope of the EBP

The proposed change initiative concerns patients with CHF and their returns to the hospital. Currently, the frequency of such unplanned readmissions within 30 days is higher than 20% (Feltner et al., 2014). This problem requires intervention because it can be resolved – most readmissions can be prevented (Fox et al., 2013). By failing to lower the rates, hospitals face multiple issues, thus putting their clients at risk as well. Health outcomes of returning patients may be worsened due to complications. Organizations with high readmission levels have to spend their resources on the same individuals, increasing the staff’s workload. Transitional Care for Patients With Congestive Heart Failure


To introduce a new system to the hospital, one has to engage all important stakeholders. Early discharge planning is mostly performed by nurses, thus making them the primary candidates for the team (Fox et al., 2013). Here, an advanced practice nurse working with CHF patients will be the main participant. Next, a physician can also be included to provide necessary advice for consulting patients. Other group members may be a geriatric nurse to discuss older patients and a nursing manager to oversee new scheduling.

The Responsibility of Team Members

Members chosen for this project have their respective duties. The nursing manager will interact with the staff to collect their opinions and evaluate their performance. Nurses and physicians will share their knowledge about treating patients with CHF. Their unique experiences will contribute to the final project, which should consider all possible arguments and pitfalls.


The literature on the topic of CHF patients’ readmission rates has many systematic reviews and meta-analyses. They present various findings connected to older patients, CHF, and ways to lower the frequency of readmissions. Most studies are targeted at nurses as they discuss quality improvement strategies that can be or were implemented in a hospital setting. Research conclusions are reliable because the analyses of most articles reveal similar EBP results.

Evidence Summary

The literature review of recent studies shows that early discharge planning along with other initiatives can greatly improve the rate of patient readmissions. Feltner et al. (2014) argue that transitional care is crucial in preventing patients from returning to the hospital with the same problem. Education is noted as one of the most effective ways to prepare individuals for their post-discharge treatment (Vedel & Khanassov, 2015).

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Recommendations for Change

These findings can become the grounds for the proposed program. Nurses should provide patients with an individual plan before discharge and guide them through their recovery. An early discharge plan is an efficient way of giving patients enough confidence in their knowledge related to CHF as well as their assuredness in the future. Transitional Care for Patients With Congestive Heart Failure


Action Plan

The implementation process will follow the mentioned above ACE Star model. First, data about hospital readmissions and current discharge planning procedures will be gathered and analyzed. Then, this information will be presented to the staff, thus establishing the necessity for change. Next, a team of professionals will be created to determine the details of planning. Personnel will be educated about early planning activities, and a number of patients will be asked to participate in the program lasting from three to six months. The results of their experience in the hospital and their health will be analyzed to assess the effects. Statistical findings regarding readmission rates before and after the intervention will be presented as outcomes.

Process, Outcomes Evaluation, and Reporting

The main desired effect is the decreased frequency of readmission of patients with CHF. The hospital can measure it using its admission data, the overall number of patients with CHF, and the number of readmitted individuals. Final reports will include these amounts as well as patients’ health outcomes, complications, and opinions about the intervention.

Next Steps

This plan can be implemented in many units for similar conditions with high readmission rates. Evidence-based results will support the programs in other departments. To make the implementation permanent, involved staff will be informed about the benefits of this program. Transitional Care for Patients With Congestive Heart Failure

Findings’ Dissemination

Internally, the results can be disseminated during meetings with the management and other nurses. Moreover, presentations can be created to represent the data visually. Externally, one can show the findings in the form of a research study targeted at other medical professionals.

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The rate of readmissions for individuals with CHF can be reduced. Early discharge planning is a beneficial intervention because it gives patients information and raises their confidence. To complete this project successfully, a nurse has to gather reliable evidence and analyze it according to the ACE Star model. The plan has to include relevant findings and data supported by multiple sources.

Transitional Care for Patients With Congestive Heart Failure

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