Transition of Care Guideline for Reducing Heart Failure Hospital Readmission

Heart failure (HF) patients are among the populations with the highest rates of hospital readmission within 30 days of discharge. Because of the 2010 Health Care Reform legislation, healthcare organizations are subject to financial penalty when a patient population exhibits excess readmissions. A significant reason for readmission of HF patients is a gap in the transition of care from hospital to home. The purpose of this doctoral project was to develop a practice guideline of best practices for transitioning HF patients from hospital to home. The transitional care model and care transitions intervention provided the theoretical underpinnings for developing this project. The research question explored whether a transition-of-care guideline would reduce hospital readmission for the HF population. The methodology used to develop the clinical practice guideline was derived from a synthesis of scholarly literature and evidence-based transitional care quality initiatives. Seven interdisciplinary experts involved in HF transition of care used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the development of the practice guideline. The scores of 6 AGREE II domains were summed and scaled to obtain a percentage of the maximum possible score for each domain. Scores showed that the clinical practice guideline was rigorous, high quality, effective in improving transition of care, and has the potential to reduce HF readmission. Positive social changes resulting from this practice guideline include an improvement in patient outcomes, a reduction in readmission rates, and a reduction in the associated financial burden to the hospital