Outcomes of an Interdisciplinary Transitional Care Quality Improvement Project on Self-Management and Health Care Use in Patients With Heart Failure
Authors: Hoover Carrie , Plamann Joy , Beckel Jean 
Published: September 2016

How to Obtain Contact Hours by Reading This Article

Instructions

1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at
http://goo.gl/gMfXaf
. To obtain contact hours you must:

1.

Read the article, “Outcomes of an Interdisciplinary Transitional Care Quality Improvement Project on Self-Management and Health Care Use in Patients With Heart Failure” found on pages 23–31, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

2.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

3.

Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until December 31, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Activity Objectives

1.

Explore the outcomes of a quasi-experimental study on care transitions on self-management and readmission rates in older adults with heart failure.

2.

Define the research outcomes to clinical practice and care of older adults with heart failure.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Heart failure (HF) accounts for most U.S. Medicare hospital admissions. The purpose of the current study was to evaluate the effectiveness of a care transitions quality improvement (QI) intervention on self-management and readmission rates in older adults with HF. A quasi-experimental, descriptive study was conducted with 66 patients with HF in three medical units in a 489-bed Midwestern acute care hospital. The intervention included a nurse coach visit and follow up, pharmacy medication education and reconciliation, and HF clinic referral. Outcomes were assessed within 48 hours of admission and 30 days after discharge using the Self-Care of Heart Failure Index and medical record review. Following implementation, readmission rates decreased from 24% to 13%. Participants demonstrated a greater improvement in use of self-management strategies to control symptoms than the non-intervention group (
p
< 0.02) and more readily identified their symptoms of HF (
p
< 0.04). The evolution of population health, with increasing numbers of older adults living at home with complex chronic conditions, will require establishment of active partnerships among pharmacists, physicians, nurse specialists, home care nurses, and patients. [
Journal of Gerontological Nursing, 43
(1), 23–31.]