The effectiveness of nurse-led interventions for reducing readmissions among hospitalized patients

The effectiveness of nurse-led interventions for reducing readmissions among hospitalized patients

Avoidable Readmissions Among Patients with Heart Failure


Heart Failure is a chronic, progressive condition where the heart muscles are unable to pump sufficient amounts of blood to meet the body’s need for blood and oxygen causing the heart to overwork. This patient population is at a higher risk of hospital readmission compared to
other chronic conditions due to its significant mortality rate and poor prognosis. According to the Centers for Disease Control and Prevention (CDC), approximately 6.5 million adults in the United States have Heart Failure (HF), with an increase to 8.5 million by 2030. In the last three
years, Heart Failure was a contributing factor to every 1-in-8 deaths while costing the nation an estimate of $30.7 billion in health care services, medications, hospital readmissions (U.S. Department of Health & Human Services, 2019). Patients with heart failure experience changes
in their quality of life and overall well-being, therefore it is important that we learn how to modify patient outcomes by suggesting and implementing interventions that exhibit continuum of care. However, it is equally important to measure the effectiveness and sustainability of these interventions on how well they can identify patients at high risk of rehospitalization (Shams et al., 2014, p. 19).
To overcome that bridge, the Centers for Medicare & Medicaid Services (CMS) introduced one such intervention, Hospital Readmissions Reduction Program (HRRP), a Medicare value-based purchasing program to reduce payments to hospitals with excess readmissions. This intervention is geared towards supporting “the national goal of improving healthcare for Americans by linking payment to the quality of hospital care” (“Hospital Readmissions Reduction Program (HRRP),” 2020). Throughout, the remainder of this paper we will discuss several transitional care interventions and elaborate on the program(s) and incentives set by CMS to reduce the 30-days hospital readmission rates for patients with heart failure.

Overview of Selected Population

For this population health intervention project, the selected population data will be carried out utilizing data from the national 5% sample of Medicare beneficiaries from the Chronic Conditions Warehouse which is the national repository for CMS data. (Kilgore et al., 2017, p. 64). The population included individuals aged ≥65 years with at least one inpatient (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnosis code of HF as the primary diagnosis. For the purpose of this project, the definition of HF includes left ventricular, right ventricular, combined and unspecified HF. To analyze the rate, cost, and length of stay of hospitalizations, the population edibility criteria also included patients with a minimum of six (6) month enrollment under Medicare Part A and B prior to the index date
and 36 months of continuous enrollment following the index month. Index date is defined by the first observed HF-associated hospitalization (Kilgore et al., 2017, p. 63-64).

Disease-specific Data

HF is a complex and collective clinical condition which results from any functional or structural cardiac impairment simultaneous with “comorbidities, which frequently include hypertension and coronary artery diseases. Cardiac dysfunction in HF is often described using values of cardiac output (Q), stroke volume (SV), or resting EF% which are abnormally low and may be useful for estimating syndrome severity and prognosis (Snyder et al., 2015, p. 207). According to the article, Two types of heart failure, (2015) the two forms of HF are systolic and diastolic differentiated based on ejection fraction (the amount of blood the heart pumps out with each contraction). A normal ejection fraction is about 55 to 65 percent, with that in mind, Systolic HF is diagnosed when the left ventricle becomes large and contracts so feebly that its blood is not expelled throughout the circulatory system efficiently; individuals with this condition have ejection fractions of 10 to 55 percent. On the other hand, diastolic heart failure is when the heart’s pumping strength is preserved, and the ejection fraction is normal. However, the ventricles don’t relax properly, which meaning they heart does not have sufficient time to fill effectively (pg. 6). As discussed earlier, currently HF affects 1-2% or approximately 6. 5 million of the general population and over 800,000 new cases are diagnosed annually. The prevalence is on a rise with an estimated increase to 8.5 million by 2030 (U.S. Department of Health & Human Services, 2019); all of which leads to increased levels of morbidity and mortality rates, decreased quality of life and increased care costs. “HF patients are particularly vulnerable to readmission; all-cause readmission rates have been reported as between 5.6% after 30 days and 45% after one year” (Duflos et al., 2016, p. 1). Therefore, improving access and effectiveness in care could be substantial in decreasing overall re-admission rates and quality of life for patients with HF.


For the purpose of this population health intervention, the setting will be at the community level, specifically, Montgomery County, Maryland. “The six hospitals operating in Montgomery County, Maryland have joined forces with a network of community-based organizations to form the Nexus Montgomery Regional Partnership. Nexus Montgomery is a hospital-led collaborative that aims to reduce avoidable or unnecessary hospital use (including readmissions), by connecting people to timely and appropriate community-based care and support service. (“ABOUT US – Nexus Montgomery,” 2018). Continuum of care is vital in managing high-risk populations, such as patients with HF, therefore care at the hospital level and discharge to the community will be a good indicator for transition of care.

Cultural Consideration

“Cultural and language differences may be important determinants of health outcomes among minority patients with chronic conditions such as HF, which require frequent interactions with the healthcare system. Patients with low acculturation or less integration into mainstream
US culture may have greater challenges with such interactions” (Peterson et al., 2012, p. 160). Certain factors that could limit an individual’s ability to services that may assist in exacerbation of HF signs and symptoms may include disease perception, language barriers, and lack of cultural competency among providers (Peterson et al., 2012, p. 160). Furthermore, in an article published by Harvard Health, certain minority groups like African Americans, Hispanics, and Asians tend to be at a greater risk for high blood pressure, diabetes, and obesity, which lead to
other chronic conditions and comorbidities compared to white Americans (Harvard Health Publishing, 2019). Therefore, for the purpose of this health intervention the sample population would include a range of racial and culturally diverse cases.

Suggested Intervention

With improvements in medical therapies and interventions management of HF has progressed over the last few decades. According to the article by Ziaeian & Fonarow, (2015), studies indicate a reduction in length of stay (LOS) and 30-day mortality in patients with HF as, however there is an increase of 30-day readmission rates and discharges to skilled nursing facilities. Among Medicare patients “the daily risk of readmission was highest on day 3 after discharge. Not until 38 days after hospitalization did the daily readmission risk decrease by 50%” (Ziaeian & Fonarow, 2016, p. 380). While the 30- day admission rates are increasing, many hospitals are switching gears to improve quality, inpatient interventions for efficiently preventing or reducing readmissions. Also, increase efforts to focus on “reducing 30-day
readmissions as they are perceived as a modifiable event after hospitalization, risk standardized readmission rates are publicly reported, and hospitals face substantial financial penalties from CMS” (Ziaeian & Fonarow, 2016, p. 383). In the era of reimbursement penalties, opportunities for collaboration amongst healthcare professionals during transitions of care (TOC) is at its prime, such efforts can “have a significant impact on patient outcomes while also contributing to the reduction of unnecessary 30-day hospital readmissions and, ultimately, healthcare-related costs” (Boykin et al., 2018, p. 45). Currently eight (8) common transition of care themes or interventions have been derived from various care models, inducing the Bridge model, Care Transition model, and the Enhanced Discharge planning Program (EDPP), Post discharge Care Transition (PDTC), Partners in Care for Congestive HF (PCCHF), etc. (Albert, 2016, p. 101).

Intervention 1: planning for discharge

Discharge planning for a patient with HF or any other chronic condition should be initiated and implemented on day one of hospitalization. An Interdisciplinary Team (IDT) including the pharmacist and any community outreach nurse or clinician should discuss the social, economic,
cultural, religious and other factors that might impact discharge planning. During discharge planning IDT should include rationale for a 7-14-day follow-up and a discussion of signs and symptoms of worsening HF should be reviewed with the patient as it might help them in recognizing factors that they previous ignored prior to the hospitalization index (Albert, 2016, p. 101).

Intervention 2: multi-professional teamwork, communication, and collaboration

“Communication failures among outpatient providers of care and patients (particularly in follow-up and tracking of patients) were associated with delays in diagnosis and treatment, and uncoordinated care among providers was associated with patient perceptions of conflicts among providers” (Albert, 2016, p. 101). Due to the complexity of patients with HF collaboration and teamwork is needed to discuss health care needs; it is prudent for HF programs to include explicit standards for multidisciplinary communication between service providers and explicit standards for processes and systems that ensure provider accountability” (Albert, 2016, p. 108). Muti-professionals communication during all stages of a hospitalization is vital in a successful discharge. Many patients and families are overwhelmed and have conflicting feelings of anxiety
or relief during transition from a hospital to a home setting; therefore, effective communication between health providers and the party involved is crucial.

Intervention 3: timely, clear, and organized information

The Care Transitions model, Project RED, and the American Heart Association (AHA)/The Joint Commission (TJC) certification program required that important discharge information be available to outpatient providers within 72 hours to 7 days of hospital discharge and include standardized content” (Albert, 2016, p. 108). All related information should be presented to patient and families in a timely and clear manner. Discharge-transition information includes all medication with dosage, timing, indication of use, treatments and services including labs, nutritional needs, etc. provided during the hospitalization. Provider information along with community resources should be handed off to patients and families in an organized manner as well.

Intervention 4: medication reconciliation and adherence

Medication safety is crucial in HF management. In various a quality improvement  initiative reports indicated 87% of patients had discrepancies between discharge and follow-up medication lists, and 26% had changed, about 42% to over 50% of patients had medication errors after hospital discharge” (Albert, 2016, p. 109). Medication adherence is an important part of patient safety, failure in doing so can cause exacerbation of HF and lead to re-hospitalization and decreased quality of life. It is important for the IDT to evaluate any patient-specific factors like fear of adverse effects of medications, costs, literacy/comprehension issues. “Careful medication reconciliation at hospital admission and discharge and at each ambulatory visit can inform health care providers about medication safety issues” (Albert, 2016, p. 109). Medication reconciliation is a time-consuming task, health care providers should develop procedures and techniques that
facilitate and standardize this.

Intervention 5: engaging social and community support groups

Many studies have found that social and community support groups for patients with HF have allowed these patients to gain assistance with household activities, meals, medication management, and more. Moreover, social and community programs provide patients with emotional and financial support in addition to physical and social support (Albert, 2016, p. 109).

Intervention 6: monitoring and managing signs and symptoms after discharge with follow ups

After discharging it is important for patients and families to monitor for new or worsening HF signs and symptoms as they can lead to early interventions and prevent hospitalization or emergency care visits. Patient education on HF should be initiated during hospitalization, at discharge, and followed through after discharge. Clinicals should “encourage patients to ask questions and to be engaged in preventive measures and HF self-care expectations. Emphasize the importance of weighing self every morning (at the same time) after urinating, before drinking, wearing the same amount of clothing, and using the same scale, discuss diet medications and ability/willingness to follow diet restrictions (Albert, 2016, p. 110). Cardiac monitoring options and strategies “that identify subclinical congestion before HF
exacerbation may increase proactive care and prevent further clinical decline and hospitalization” (Albert, 2016, p. 110).

Intervention 7: outpatient follow-up

“Early outpatient follow-up is an important point of interface for providers and patients with HF” (Albert, 2016, p. 111). Follow-up visits re-assess patient’s current status, medication management and reconciliation, reinforce patient education, further assess social and community
support and barriers and discussion of advanced-care planning (Albert, 2016, p. 111). It has been reported that 30-day re-hospitalization rates decrease when 7-day follow up visits are implemented.

Intervention 8: advanced care planning and palliative/rend-of life care

According to Albert, (2016) it is important for all multidisciplinary team members to discuss HF chronicity and prognosis with patients and families, including the potential need for palliative care and the possibility of cardiac failure or sudden death (pg. 111). Many patients and
families have misconceptions about the chronic and deteriorating nature of HF, therefore setting realistic expectations and discussing palliative care needs might promote the need for advanced therapy and adherence of self-care and medication management.

Budgetary Needs and Possible Funding

The Maryland Health Services Cost Review Commission has awarded the Nexus Montgomery partnership program with $7.6 million to address the challenges affecting the health and safety of the county and to “implement or expand initiatives that will improve the health
status of those most at risk of avoidable hospital use” (“Montgomery County Hospitals Announce Funding of Nexus Montgomery Regional Partnership,” 2018).

Timeline for Implementation and Evaluation Methods

The Nexus Mo ntgomery program initat4d in 2018 and plans to implement success interventions and transition of care models throughout the county with a 5-year plan to begin with. The first year The Nexus Montgomery program partnered with six (6) local hospitals and
strategized plans to recruit and organize ways to improve quality and care for the patients in the community. The program participants meet quarterly and monthly if needed to discuss progress and barriers. Each of the six hospitals have a set goal and target re-admission rate for each
quarter, furthermore, these hospitals work in conjunction with preferred SNFs and home health agencies to ensure community and/or SNF discharges are effective and quality care is continued throughout, all in effort to reduce readmissions. Hospitals and adjacent facilities that do not meet the target goals are offered 1:1 focused meetings to understand the barriers and help improve their outcomes.

QSEN Competencies

In 2003 Institue of Medicine (IOM) published a report called Health Professions  Education, which highlighted the importance of healthcare quality and safety; this lead to the  development of the Quality and Safety Education for Nurses (QSEN) and six (6) core “quality and safety program competencies that are essential in closing the gap between the quality chasm. These competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics” (Lyle-Edrosolo & Waxman, 2016, p. 73). In management of HF and reduce 30-day readmission rates it is important to recognize the need for teamwork, collaboration, and delivering patient-centered care. Teamwork and collaboration as discussed are crucial in the transition care model as patients require education,
follow-up and support once they are at a community level or in an acute care setting. Patient- centered care is important as the multidisciplinary team should evaluate patient-specific barriers such as social, economical, or personal to implement effective ways in management thir disease process and improve quality of life.

Christian Worldview

John 13:34-35 reads, “A new commandment I give to you, that you love one another, even as I have loved you, that you also love one another. “By this all men will know that you are My disciples, if you have love for one another.” As a Christian nurse it is important to recognize
the struggles and the success of individuals all we care for. Upon deciding to become a nurse, it was important to understand that not everyone who will be encountered during this journey will be “people of God” many may have done wrong and drifted from the path God had created for
us, however it is up to us to lead by his example and love all as one. Working in a prison and different healthcare settings, this theory has been tested a few times, however keeping in mind that God is the ultimate judge and will guide us all is kept me going. In conclusion, reducing the
30-day readmission rate is a crucial initiative and understanding the need for opportunities that would improve delivery of care, encourage collaboration and teamwork all while providing patient-centered and quality care are instrumental.


Nexus Montgomery. (2018). Nexus  Montgomery.
Albert, N. M. (2016). A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100- 113.
Boykin, A., Wright, D., Stevens, L., & Gardner, L. (2018). Interprofessional care collaboration for patients with heart failure. American Journal of Health-System Pharmacy, 75(1), 45- 49.
Deedwania, P., & Rathi, S. (2017). Epidemiology and Pathophysiology of Heart Failure. Medical Clinics of North America, 96(5), 881-890.
Duflos, C. M., Solecki, K., Papinaud, L., Georgescu, V., Roubille, F., & Mercier, G. (2016). The Intensity of Primary Care for Heart Failure Patients: A Determinant of Readmissions? The CarPaths Study: A French Region-Wide Analysis. PLOS ONE, 11(10), 1-
Harvard Health Publishing. (2019, September 24). Race and Ethnicity: Clues to Your Heart  Disease Risk? Harvard Health.
Hospital Readmissions Reduction Program (HRRP). (2020, February 11). CMS Homepage |
Kilgore, M., Patel, H., Kielhorn, A., Maya, J., & Sharma, P. (2017). Economic burden of hospitalizations of Medicare beneficiaries with heart failure. Risk Management and  Healthcare Policy, Volume 10, 63-70.
Lyle-Edrosolo, G., & Waxman, K. (2016). Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards
Crosswalk. Nurse Leader, 14(1), 70-75.
Montgomery County Hospitals Announce Funding of Nexus Montgomery Regional Partnership(2018). Adventist HealthCare | Maryland.
Peterson, P. N., Campagna, E. J., Maravi, M., Allen, L. A., Bull, S., Steiner, J. F.,Havranek, E. P., Dickinson, L. M., & Masoudi, F. A. (2012). Acculturation and Outcomes Among Patients With Heart Failure. Circulation: Heart Failure, 5(2), 160-166.
Shams, I., Ajorlou, S., & Yang, K. (2014). A predictive analytics approach to reducing 30-day avoidable readmissions among patients with heart failure, acute myocardial infarction,pneumonia, or COPD. Health Care Management Science, 18(1), 19-34.
Snyder, E. M., Van Iterson, E. H., & Olson, T. P. (2015). Clinical Classification of Heart Failure Patients Using Cardiac Function during Exercise. Exercise and Sport Sciences  Reviews, 43(4), 204-213.
Two types of heart failure. (2015). Focus on Healthy Aging, 18(1), 6. U.S. Department of Health & Human Services. (2019, December 9). Heart Failure. Centers for Disease Control and Prevention.
Ziaeian, B., & Fonarow, G. (2016). The Prevention of Hospital Readmissions in Heart Failure. Progress in Cardiovascular Diseases, 58, 379-


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