Date of Conferral



Doctor of Nursing Practice (DNP)




Barbara Niedz


Every year, thousands of congestive heart failure (CHF) patients are readmitted to the hospital within 30 days of discharge. There is a gap in practice in the care continuum of patients with CHF within the transition from hospital to home. One of the factors known to increase a patient's risk for readmission is the lack of patient engagement and self-efficacy regarding the treatment plan. The purpose of this project was to implement a transition of care practice guideline that consisted of the use of a risk identification tool, a customized care plan for patients at high risk for readmission, and a discharge checklist crafted specifically for CHF patients who are at risk for readmission. The practice initiative utilized the Iowa model of Evidence Based Practice as a framework and the teach-back method for discharge education. A sample of 193 patients admitted during a 1-month timeframe fit the inclusion criteria and was generated from the electronic health record. Descriptive statistics were used to analyze the data collected during implementation. In fact, of the 106 CHF patients who benefited from the CHF checklist only 2 required readmission within 30 days, a 1.8% 30 day readmission rate. As compared to the 22% readmission rate experienced in 2017, this represented a considerable improvement, albeit preliminary. Efforts to improve the lives of patients and their families will ultimately serve society well, making a significant contribution to positive social change. Providing comprehensive discharge education to patients using the teach-back method to assess the retention of knowledge will help close the gap in the transition of care between hospital and home, ultimately reducing CHF readmissions.