Date of Conferral



Doctor of Nursing Practice (DNP)




Mattie Burton


Heart failure (HF) is one of the main reasons for hospitalizations and readmissions. A local hospital collaborated with a skilled nursing facility (SNF) in 2012 with the goal of reducing systolic HF readmissions. This collaboration consisted of having an Advanced Practice Nurse (APN) who specializes in cardiac care follow up with all patients discharged from the hospital to the SNF with a diagnosis of systolic HF. The practice-focused question for this project addressed whether early follow-up and continuity of care by a cardiac APN would decrease hospital readmission within 30 days in patients with systolic HF who are discharged to a SNF. This project evaluated the effectiveness of this intervention using the Donabedian quality framework. The Donabedian quality framework consists of 3 concepts: structure, process, and outcome. Sources of evidence were obtained through the electronic medical record systems at both facilities. Total of 1,009 patients were seen by the cardiac APN from 2012 to 2016. Results showed a steady decline in readmissions from 47% to 6%. This supported the conclusion that collaboration between hospitals and SNFs post hospital discharge is essential to improve the management and readmissions of HF. Specialized APNs, such as the cardiac APN in this study, may be more effective in the management and coordination of care for a specific patient population. Implications of this successful collaboration include better working relationships between nonaffiliated health care facilities, improved patient care outcomes, decreased readmissions for HF patients, and an improved community health care system.