Graduation Semester and Year
Fall 2026
Language
English
Document Type
DNP Project
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Kimberly Sinischalchi
Second Advisor
Yungfei Kao
Abstract
Background: Heart failure (HF) is associated with substantial morbidity, mortality, healthcare utilization, and risk of unplanned hospital readmission. Gaps in structured discharge planning and post-discharge follow-up may contribute to preventable readmissions. Purpose: This quality improvement (QI) project aimed to implement a multidisciplinary transitional care bundle to strengthen care coordination, improve the post-discharge pathway, and reduce unplanned heart failure hospital readmissions (UHFHR). Methods: The project included 20 adults hospitalized with HF in a 56-bed telemetry unit in a South Texas acute care hospital. The eight-week intervention included social determinants of health (SDoH) assessment, nursing-led discharge education, HF clinic follow-up within 14 days, and telephone follow-up within two business days. The Plan-Do-Study-Act framework guided implementation. Descriptive statistics were used to evaluate process measures and outcomes. Results: All participants (100%) received SDoH assessment, discharged education, and scheduled HF clinic follow-up. Telephone follow-up was completed for 95% of participants (n = 19). The cumulative QI project patient satisfaction score was 96%. Ten percent of participants (n = 2) experienced a UHFHR, while 90% of participants (n = 18) remained readmission-free. Conclusion: Project findings support the feasibility of integrating multidisciplinary transitional care into routine practice and provide a foundation for sustainable improvement and adaptation to other chronic disease populations.
Keywords
heart failure, heart failure education, transitional care, social determinate of health, and unplanned hospital readmission.
Disciplines
Medicine and Health Sciences | Nursing
License
This work is licensed under a Creative Commons Attribution 4.0 International License.
Recommended Citation
Stahler, Pearl Zehua, "A Multidisciplinary Transitional Care Bundle to Reduce Hospital Readmission in Patients with Heart Failure: A Quality Improvement Project" (2026). Doctor of Nursing Practice (DNP) Scholarly Projects. 22.
https://mavmatrix.uta.edu/nursing_dnpprojects2/22