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Care Transition Gaps: Risk Identification and Intervention

Hospital readmissions related to chronic heart failure (CHF) are costly, widespread, and often avoidable. Patient education that includes diagnosis, causes, medications, diet, exercise, and exacerbation warning signs has been shown to reduce the number of CHF readmissions. The purpose of this study was to use risk stratification to identify CHF patients at high risk for 30-day readmission. Once a high-risk CHF patient was identified, nursing interventions would be triggered to reduce readmissions and close the gaps in the continuum of care following acute care admission. Transitions of care theory was used as the framework for this project. The methodology had a quality improvement focus. The patient population consisted of high-risk CHF patients (n = 25) with NYHA classification of II-IV using the risk identification tool. Patients were identified using the tool, were followed for 30 days, and received nursing interventions to reduce the possibility of readmission. Only one of the identified patients was readmitted within 30 days for a diagnosis unrelated to CHF, resulting in no readmissions within this sub group. This study suggests that risk stratification can identify and direct resources to CHF patients, decreasing their likelihood for readmission. Nurse leaders can use standardized tools such as the risk identification tool, thereby reducing readmissions along with associated costs for readmissions.

Identiferoai:union.ndltd.org:waldenu.edu/oai:scholarworks.waldenu.edu:dissertations-1445
Date01 January 2015
CreatorsJongsma, Michael Howard
PublisherScholarWorks
Source SetsWalden University
LanguageEnglish
Detected LanguageEnglish
Typetext
Formatapplication/pdf
SourceWalden Dissertations and Doctoral Studies

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