Telephone Intervention by Student Nurse Externs for Discharged Heart Failure Patients

Saturday, 16 November 2013

Rae E. G. Charos, RN, BSN, MSN, FNP
Administration, Dignity Health St. Joseph's Medical Center, Stockton, CA

Learning Objective 1: Name the common reasons heart failure patients are readmitted to acute care hospitals within the first thirty days after discharge.

Learning Objective 2: Explain the impact of early hosptial readmissions on hospitals and patients.

Telephone Intervention by Student Nurse Externs with Recently Hospitalized Heart Failure Patients to Prevent Hospital Readmission


Rae E. G. Charos

University of Nevada, Reno

            A telephone intervention for patient recently discharged from an acute care hospital is being tested in this proposed Doctor of Nursing Practice (DNP) capstone project.

The literature reveals many strategies that have the potential to reduce readmissions of the CHF patient, however a lack of definitive evidence about which hospital practices are effective, in addition to the resource intensiveness of many of the strategies, suggests the need to test a specific, cost effective strategy. 

This change project will test a specific transition strategy, the use of telephone contact within the first 30 days of discharge as the means for readmission prevention.  The proposed strategy is that a Student Nurse Extern (SNE) will make telephone contact with the patient/caregiver within 48 hours of discharge with continued daily calls for two weeks, followed by weekly contact for the first 30 days after hospital discharge.  The investigator, the Chief Nurse Executive (CNE), will have direct oversight of the project. A script developed by the investigator that addresses medication compliance, weight gain, and symptoms will be used by the SNE.   A Registered Nurse will supervise and be directly available to the SNE to address any questions from the SNE and assist with management of complex clinical situations.  The use of the SNEs is cost effective for the facility and also will provide the SNEs with exposure to the continuum of care.