Essay on Application of a Validated Transitional Care Tool in Decreasing Hospital Readmission Rates Among Geriatric Patients With CHF

Published: 2021/11/24
Number of words: 2318


Hospital readmissions among patients with congestive heart failure (CHF) are a rising cause of global concern among health care professionals and government agencies (Ogbemudia & Asekhame, 2016). Increased hospital readmissions continue to place a high burden on patients who suffer from physical pain and mental health, treatment costs, health insurance premiums, and hospital resources (Sukul et al., 2017). In the United States, the 30-day readmission rate for patients with CHF rose from 17% in 1993 to 20% in 2006. Patterns of hospital readmission are linked to the length of hospital stays, clinical factors, age of the patient (geriatric patients are most affected), and impacts of comorbidities. Hospital readmission rates pose significant health challenges and hospital-based strategies show reduced effect in curtailing the problem. Recent trend shows increased uptake of patient-centered strategies such as the inclusion of technology through telemonitoring measures. Among patient-centered strategies to reduce readmission rates among patients with CHF is the use of the validated transitional care protocol in nursing facilities.

Proposed Question

Congestive heart failure (CHF) places a heavy economic and social burden on health care systems, especially relating to hospital readmissions (Storm et al., 2014). Older adults are most affected because of the lack of consistency in implementing health plans and poor understanding of treatment plans, nonadherence to medical therapy, irregular follow-up with health professionals, and lack of awareness of CHF symptom exacerbation. Thus, there exists a need for the implementation of a patient-centered validated tool to help in the improvement of the quality of health services to older patients with CHF. The PICOT question formulated for the research study is as follows: Among geriatric patients diagnosed with CHF in a skilled nursing facility (P), what is the efficiency of implementing a validated transitional care protocol for preventing hospital readmission (I), compared to usual care protocols for preventing re-hospitalization (C), in reducing 30-day CHF readmission (O), within two months (T)? thus, the study focuses on collecting and appraising evidence on the use of the validated transitional care protocol to assess its applicability and efficiency in use to reduce re-admissions among geriatric patients with CHF.

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Evidence from Research and Theory

Plakogiannis and others (2019) showed that the implementation of a patient-centered transitional care strategy among patients with CHF helped in reducing the rate of readmissions in hospitals. The authors conducted a retrospective manual chart review study for patients with CHF who had been categorized as high-risk for hospital readmissions. The hospital involved in the study used a team of health professionals drawn from multiple disciplines to conduct follow-up interview questions with patients. The health professionals discussed with the patients through telephone to assess various aspects of care including indications for therapy, dose adherence, duration, evaluating adherence to physician appointments, and reinforcing signs of fluid overload. The pilot program lasted six months and the authors noted that the 30-day hospital readmission rate for CHF patients after the introduction of the transitional care program fell from 24.43% to 11.45%. The results from the pilot study were supported by 90-day readmission rates which fell from 38.17% to 22.90%, showing that the implementation of a transitional care program helps to reduce hospital readmission rates for patients with heart failure.

Doris and others (2015) assessed the effects of nurse-implemented transitional care for individuals with CHF in Hong Kong. The authors used a modified version of transitional care strategies and conducted a randomized control trial university-affiliated study involving patients diagnosed with CHF. After screening and including 178 individuals for the study, nurses implemented the intervention strategy which included pre-discharge visits, home-care-based visits, follow-up through phone calls, and the provision of a cardiac nurse for evaluation. The overall intervention included the assessment of the health status of patients, assessment of disease progress, customization of educational and supportive interventions, skills training to patients, review, and adjustment of self-care goals, provision of advice to patients, and monitoring CHF symptom severity. The results of the study showed that the implementation of transition care strategies lowered hospital readmission rates at 8.1% compared to the usual care group at 16.3%; while the participants administered with transitional care interventions had shorter hospital stays and showed better self-care measures.

Chan, Lin, and Wong (2016) conducted a literature review to evaluate the effectiveness of transitional care models in reducing the rate of hospital readmissions among patients with CHF in South East Asia. The authors assessed various studies incorporating nurse-led interventions through partnering in care, social worker-led interventions focusing on well-being, structured phone support, and telemonitoring for remote follow-up. Chan and others (2016) showed that nurse-led transitional care interventions reduced emergency department visits, lowered hospital readmission rates, and enhanced intensive education to the patient. Social worker-led post-discharge transitional care interventions were shown to focus on psycho-social issues (which affect adherence to treatment plans), improve follow-up appointments but did not show reduced readmission rates. The use of the structured telephone support intervention improves the ease of organization, enhances cost-effectiveness, and enhanced cooperation rates from patients who consider home visits intrusive. Chan et al. (2016) conclude that nurse-led transitional care intervention models conducted in partnership with multidisciplinary care teams provide the best results for patients with CHF.

Soto and others (2018) evaluated the effects of the implementation of a structured transitional care pathway among low-risk cardiac patients on emergency department discharges, 30-day readmissions, and institutional returns. The authors used a prospective study to assess rates of discharge from the emergency department, 30-day ED revisits and admission rates, and 30-day returns for myocardial infarction. The results of the study showed that the 30-day readmission due to myocardial infarction was at 0.35% while the rate of readmission at second ED fell from 45.6% to 37.7%. Additionally, the authors noted that institutional revenue was reduced by $300 for each patient throughout the period.

Appraisal of Evidence

The evidence studies and research were appraised and assessed for the validity of each study, predicted impacts on the proposed question, and potential applicability to the question. Plakogiannis and others (2019) showed high validity after the authors conducted a post hoc power analysis which showed a high correlation between the studied variables and the outcome from the variables at an alpha value of 0.05 related to the power of the statistically significant difference between 0.90 and 0.99. The study by Plakogiannis and others (2019) shows that the implementation of the transitional care intervention helps to reduce readmission rates for HF among patients, and the authors predict similar impacts on other chronic conditions such as pulmonary disease, renal diseases, and other non-cardiac conditions. The study is applicable to critical care facilities and other nursing facilities to improve the health of patients with CHF.

The article by Yu and others (2015) showed high validity because the nursing interventions underwent coding processes and tracking through documentation in the nurse-participant encounter. The authors used validated scales and measurement tools to assess for different variables. Some of the tools used included the Self-Care Heart Failure Index, the Dutch Heart Failure Knowledge Scale, the Minnesota Living with Heart Failure Questionnaire, and the EuroQoL 5-Dimensional Questionnaire (Yu et al., 2015). The study is useful in combination with cultural-based interventions to decrease the length of stays in hospitals and to improve self-care among patients (Yu et al., 2015). Specifically, the study was conducted using a Chinese participant sample and the predicted impacts within an American population is similar. The authors note that the intervention proposed within the study could be implemented in large-scale hospital settings where health professionals are diverse and cultural awareness is not a barrier to implementation (Yu et al., 2015).

The article by Chan and others (2016) shows moderate validity because there was a deficiency in the use of validated tools and measurements in the assessment of the reviewed articles (Patino & Ferreira, 2018). The review process failed to conduct any reliability and consistency test to determine the accuracy of the data. However, the authors evaluated each article independently and provided conclusions related to the methodology and findings of each study thereby enhancing the reliability and validity of the review process. Through the article, the implementation of the study findings shows a reduction of hospital readmission rates by 31% and a reduction of hospital stay durations by 31%. The potential application of the intervention should be in hospital care facilities with the significant technological capacity to support telemonitoring services and within teams of health care professionals with diversity in collaboration with community care services such as nursing home care, hospice care, home rehabilitation, and community services.

The study by Soto and others (2018) showed high validity because the research design incorporated Fisher’s exact test to determine the suitability of the sample size, and relied on the coding system developed by the International Classification of Diseases (ICD). The HEART TRACKS study included various data analyses including the Mann-Whitney U test with alpha value at 0.05. The study protocol showed high consistency with the predicted outcomes. The predicted impacts of the study include financial costs of $300 per patient showing a high cost to benefit ratio to the hospital and no significant reductions in 30-day cardiac-related revisits to the ED. Although the study design is applicable in all types of clinical settings, it is appropriate for hospitals with operational community care facilities to allow for the seamless transfer of patients from hospital-based settings to low-cost ambulatory settings. The design of the study is expected to reduce 30-day ED revisit rates and to moderately improve patient outcomes.

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Synthesis of Findings and Conclusion

The findings from the evidence show that the transitional care model is a strategic and impactful care model used to facilitate the transition of care from acute care and critical care facilities to home-based care facilities allowing the development of new care approaches. The application of transitional care models in various interventions has been shown to present various results and outcomes for patients, health care facilities, and patient outcomes. All the studies analyzed show that the hospital readmission rate for older patients with CHF has been reduced significantly. Although the extent and significance of reduction differ among studies, all the studies converge on the theme that patients are less likely to require emergency care services when they are regularly assessed and monitored by nursing professionals. Among patients with CHF, the interventions converge on the use of multidisciplinary care teams involving a diverse array of health professionals and cultural awareness of different patient demographics. Thus, it is clear that the use of the validated transitional care tool to reduce 30-day hospital readmission rates will have a higher effect than usual care approaches. The conclusion is drawn from the realization that health care professionals can assess patients’ health status to develop treatment plans favorable for them in their home settings while promoting adherence to existing health plans among various patients.

Limitations of Project and Proposed Solutions

The major limitation of the study is the lack of congruence and standardization of transitional care interventions among various health professionals to result in a specific interventional model for use (Vedel & Khanassov, 2015). The second limitation for the project is the lack of cooperation among older adults who might present with debilitating mental health disorders limiting the application of the transitional care model. Related to the proposed solution, Soto and others (2018) show an increased cost to health care facilities for the provision of telehealth and telemonitoring services to home-based patients. Additionally, some patients reluctant to authorize home visits might limit the outcome of the intervention as telephone monitoring is less reliable due to dependence on self-reported patient information (Vedel & Khanassov, 2015). Finally, the outcomes of the interventions might result in significant health disparities especially for patients drawn from low-income households and where geographical location is a barrier (Mai Ba et al., 2020). The cost of implementation of telemonitoring services is high while the use of modern technology such as smart devices creates a barrier for universal use by patients.


Soto, G. E., Huenefeldt, E. A., Hengst, M. N., Reimer, A. J., Samuel, S. K., Samuel, S. K., & Utts, S. J. (2018). Implementation and impact analysis of a transitional care pathway for patients presenting to the emergency department with cardiac-related complaints. BMC health services research18(1), 672.

Chan, W. X., Lin, W., & Wong, R. C. C. (2016). Transitional care to reduce heart failure readmission rates in South East Asia. Cardiac failure review2(2), 85.

Plakogiannis, R., Mola, A., Sinha, S., Stefanidis, A., Oh, H., & Katz, S. (2019). Impact of pharmacy student–driven postdischarge telephone calls on heart failure hospital readmission rates: A pilot program. Hospital pharmacy54(2), 100-104.

Yu, D. S., Lee, D. T., Stewart, S., Thompson, D. R., Choi, K. C., & Yu, C. M. (2015). Effect of nurse‐implemented transitional care for Chinese individuals with chronic heart failure in Hong Kong: a randomized controlled trial. Journal of the American Geriatrics Society63(8), 1583-1593.

Patino, C. M., & Ferreira, J. C. (2018). Internal and external validity: can you apply research study results to your patients?. Jornal brasileiro de pneumologia44(3), 183-183.

Storm, M., Groene, O., Testad, I., Dyrstad, D. N., Heskestad, R. N., & Aase, K. (2014). Quality and safety in the transitional care of the elderly (phase 2): the study protocol of a quasi-experimental intervention study for a cross-level educational programme. BMJ open4(7).

Ogbemudia, E. J., & Asekhame, J. (2016). Rehospitalization for heart failure in the elderly. Saudi medical journal37(10), 1144.

Sukul, D., Sinha, S. S., Ryan, A. M., Sjoding, M. W., Hummel, S. L., & Nallamothu, B. K. (2017). Patterns of readmissions for three common conditions among younger US adults. The American journal of medicine130(10), 1220-e1.

Vedel, I., & Khanassov, V. (2015). Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. The annals of family medicine13(6), 562-571.

Mai Ba, H., Son, Y. J., Lee, K., & Kim, B. H. (2020). Transitional Care Interventions for Patients with Heart Failure: An Integrative Review. International journal of environmental research and public health17(8), 2925.

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