- Stefan Ball
- Spring 2026
- NURS 495 Kelsey Pascoe, PhD, RN
Abstract
Heart failure (HF) remains a leading cause of hospital readmissions, contributing to increased healthcare costs and adverse patient outcomes. Evidence suggests that inadequate post-discharge support, including poor understanding of self-management and limited follow-up care, significantly contributes to preventable readmissions. This project aims to examine the effectiveness of post-discharge education and structured follow-up interventions in reducing 30-day readmission rates among patients with heart failure. A review of current literature, including systematic reviews and meta-analyses, was conducted to evaluate evidence-based strategies such as nurse-led education, telehealth monitoring, and early outpatient follow-up. Findings consistently demonstrate that comprehensive discharge education focused on medication adherence, symptom recognition, dietary management, and daily weight monitoring combined with timely follow-up, significantly reduces readmission rates and improves patient outcomes. The project supports the implementation of standardized, nurse-driven discharge protocols and enhanced care coordination as key interventions. Integrating these evidence-based practices into clinical settings may improve patient self-management, reduce hospital utilization, and promote safer transitions of care for individuals with heart failure.
Keywords: Heart failure, hospital readmissions, post-discharge education, transitional care, nurse-led interventions, telehealth monitoring, care coordination
