Background: Unplanned hospital readmissions occur frequently in the United States (U.S.), placing great financial burdens on the healthcare industry and creating complications for patients. Approximately 20% of patients are readmitted to the hospital within 30 days of discharge and three-quarters of these readmissions could have been prevented (Chaudhry, Barton, Mattera, Spertus, & Krumhoiz, 2006). A 30-day hospital readmission rate of 19.6% among Medicare fee-for service enrollees has also been reported. The estimated cost of approximately US $17.4 billion in unplanned hospital readmissions for Heart failure (HF) complications has been reported (Purdy 2012). Telephone follow-up is thought to be an effective strategy in reducing the 30- day readmission rate for adults with heart failure, and this intervention will be explored. Early readmission is a common and costly occurrence, particularly among HF patients. HF remains a high risk, chronic disease and readmission within 30 days is common. Because of the complexity of HF treatment, discharged patients find it difficult to manage all required aspects of their care effectively. Telephone follow-up addresses gaps of uncertainty that may exist and allows patients to gain clarity or further explanation about their conditions.
Objective: The purpose of this DNP scholarly project is to design, implement and evaluate an NP telephone follow-up policy for HF patients discharged from the targeted sub-acute rehabilitative institution to a home setting.

Design and Methods: The design for this project is a quality improvement initiative project. The setting will include a Long term care / sub-acute rehabilitative institution where the DNP student leader made phone calls to patients in their places of residence (to include personal homes and/or other residential sites). Patients were advised about the project and asked to sign a participation consent form prior to discharge from the LTC/ sub-acute rehabilitative setting if they are willing to participate. The telephone call, and subsequent interventions to patient, occurred only after patients were discharged to their homes or place of residence.

Sample: A sample of 44 patients total was studied. Retrospective chart reviews were completed and data collected on 21 people. The other 23 people were contacted 1-3 days post discharge and then weekly for 30 days. Patients were considered for participation in the project based on certain predetermined criteria, as follows. Be scheduled for discharge from the facility to their place of residency within the project implementation timeframe, have a diagnosis of HF for their most recent hospital admission, primary admission diagnosis of heart failure needs to be clearly noted in the medical record. Be alert, verbally responsive, and able to hear clearly, and speak/understand English and have a working telephone.

Results: no differences between the groups from the demographic characteristics age, gender, and race. Participants largely female, Caucasian between ages 71-80. Mean age 70.45. . Retrospective chart reviewed indicated 43.47% of the intervention group and 47.61% of the non-intervention group were readmitted within 30 days prior to this last admission. Decrease noted in the 30 days readmission rate for both groups. Patients who received telephone intervention had a 17.39% readmission rate post 30 days compared to those who did not receive the intervention at 38% readmission rate

Conclusions: The results of this study demonstrates that telephone follow-up provided by an NP post discharge from a LTC facility , at least initially decreased 30 day hospital readmission, but the difference did not reach statistical significance.