Date of Conferral



Doctor of Nursing Practice (DNP)




Cassandra Taylor


Hospital administrators strive to reduce readmission and over use of the acute care setting for chronic health conditions. Historically hospitals have focused on readmission prevention strategies to improve the transition of patients from the hospital to the community and although the causes of a hospital readmission may span multiple providers along the continuum of care, the hospital is currently the only provider being penalized. The project facility implemented a readmission reduction strategy, Re-Engineered Discharge (Project RED), as a means to reduce readmissions and yet continued to have high readmission rates for heart failure (HF) patients. The continued high rate of readmissions led to the practice focused question, which examined the process of developing a discharge phone call script specific for HF patients as a way to reduce readmissions for HF patients. Kristin Swanson's structure of caring model provided the nursing framework for this project with a purpose to plan a telephone call follow up program for HF patients after hospital discharge. The project planning was accomplished in conjunction with the facility's readmission reduction team/LEAN team, resulting in a script about the most prevalent issues among HF patients. Kotter's 8 step change model will be used as a guide for the implementation of the telephone call follow up program at a later date. Readmission rates for HF patients will be monitored monthly as an outcome evaluation measure. Project team members provided evaluation of the project which demonstrated satisfaction and success of the planning process. The results of this project will bring about social change by providing access to healthcare providers regardless the socioeconomic status of the patient and by decreasing the use of acute care setting unnecessarily for chronic conditions.

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