Date of Award

January 2021

Document Type

Open Access Thesis

Degree Name

Doctor of Nursing Practice (DNP)


Yale University School of Nursing

First Advisor

M T. Knobf


Abstract: Heart Failure is one of the leading causes of hospital readmissions. Heart Failure affects approximately 6.2 million adults in the United States and costs the nation an estimated $30.7 billion each year (Farmarkis, 2017). Prevalence is projected to increase 25% by 2030 (Savarese, 2017). Approximately 50% of patients who are discharged are readmitted within 6 months and 24% within 30 days (Desai & Stevenson, 2012). About half the population with heart failure dies within 5 years of diagnosis (CDC, 2016). Despite advances in the treatment of heart failure, patient optimization remains a challenge for health care providers. The initiation of self-care is a multifaceted process which has been proven effective in reducing hospital readmission and mortality rates. Research supports optimization of care during hospitalization with definitive transition of care plans. A supportive environment, motivation, and adequate care programs implementing effective educational methodologies that build self-care skills should be recommended to health care providers and their families (Siabanni, 2013). The current recommendations form the AHA GWTG HF are that patients receive education on early symptom recognition, diet, medications, and an individualized treatment plan before being discharged. A Pilot Program which enrolled 47 patients was implemented on the Telemetry unit. Patients were educated on their disease process, medications, diet, exercise, life-style modification, and early symptom recognition. Follow up phone calls were made within 48 -72 hours of discharge and patients were seen by a Cardiologist within a week of discharge. There was 16.6% decrease in 30 -day readmission rates for HF after the implementation of the Pilot program.


This is an Open Access Thesis.

Open Access

This Article is Open Access