research and EBP concepts

Assignment Prompt

The purpose of the signature assignment is for students to apply the research and EBP concepts they have learned in this course and develop a framework for the initial steps of the student’s capstone project. The assignment allows the student to initiate the steps for planning, researching and developing an evidence-based practice intervention project proposal.

On or before Day 7, of week eight each student will submit his or her final proposal paper to the week eight assignment. This formal paper will include and expand upon work completed thus far in prior assignments.

Essential Components of the Final Project Proposal will include:

1. Introduction– Provide an introduction to your topic or project. The introduction gives the reader an accurate, concrete understanding what the project will cover and what can be gained from implementation of this project.

2. Overview of the Problem – Discuss the problem, why the problem is worth exploring and the potential contribution of the proposed project to the discipline of nursing.

3. Project Purpose Statement – Provide a declarative sentence or two which summarizes the specific topic and goals of the project.

4. Background and Significance – State the importance of the problem and emphasize what is innovative about your proposed project. Discuss the potential impact of your project on your anticipated results to the betterment of health and/or health outcomes.

5. PICOt formatted Clinical Project Question(s)– Provide the Population, Intervention, Comparison, Expected Outcomes and Timeframe for the proposed project.

6. Literature Review – Provide the key terms used to guide a search for evidence and discuss at least five (5) summaries of relevant, credible, recent, evidence-based research studies to support the project proposal.

7. Critical Appraisal of Literature – Discuss the strengths and weaknesses of the evidence, what is known from the evidence and what gaps in evidence were found from the appraisal of evidence-based research studies.

8. Develop an EBP Standard – Describe two to three interventions (or a bundle of care) from the evidence and discuss how individual patient preferences or the preferences of others will be considered.

9. Implications – Summarize the potential contributions of the proposed project for nursing research, education and practice.



· Due: Friday, 11:59 pm PT

· Length: A minimum of 8 pages and a maximum of 10 pages (excluding the title and reference pages)

· Format: Formal scholarly paper in APA 6th ed format

· Reference Citations: A minimum of five, recent (past five years), peer-reviewed scholarly references cited in APA 6th ed format.

· Keep Turnitin 0% or below 15%

Post-discharge Intervention to Reduce Hospital Readmission in Older Adults with Heart Failure


Congestive heart failure (CHF) is the most common reason for frequent hospitalization among elderly 65 years of age or older in the US. The condition has the highest 30-day readmission rate among medical and surgical in-patient due to ineffective post-discharge care and interventions (Nair, 2020). Heart failure patients need constant attention and monitoring to ensure that any changes and negative outcomes are identified and addressed in time to prevent avoidable and unnecessary readmissions (Akande, k2017). However, most healthcare organizations lack effective frameworks to ensure that heart failure patients continue receiving care and attention even after being discharged. Therefore, this paper will explore the issue of 30-day readmissions among patients suffering from heart failure and different shortfalls the post-discharge care that have contributed to the high 30-day heart failure readmission rates in the US. This project is designed to research and incorporate current successful post-discharge nursing approaches to reduce complications that cause heart failure in older patients to be hospitalized. The project’s outcome will include interventions that can be used in their practices by nurses and advanced practice nurses to improve the health outcomes of their clients and help minimize the number of readmissions of heart failure to health care organizations.


Problem Overview

Heart Failure is the number one cause of death in the US. It is estimated that approximately 6.2 million US citizens have Heart Failure. The prevalence of HF is estimated to rise by 46 % from 2012 to 2030, with more than 8 million adults living with a chronic condition. In 2018, heart failure was directly attributed to 379,800 deaths in the US or 13.4% of all deaths in the US (CDC, 2020). Heart failure is a complex condition that needs proper care in-patient and post-discharge care. Statistics show that 20% of heart failure patients get readmitted within 30 days after they have been discharged (O’Connor, 2017). One of the major causes of high readmission rates among heart failure patients is healthcare failure in the provision of post-discharge care (Felix, Seaberg, Bursac, Thostenson & Stewart, 2015). For patients with heart failure, proper discharge planning is important. However, some healthcare institutions have uncoordinated and unsatisfactory discharge planning processes, which greatly disadvantage the patients and their families. Discharge planning should be conducted in a comprehensive manner to prepare the patients and their families for post-discharge care (Gonçalves-Bradley, Lannin, Clemson, Cameron & Shepperd, 2016). Heart failure patients need proper access to community-based resources, psychosocial and physical support from their families, and a conducive environment that will facilitate proper recovery and achievement of the set care goals. For these aspects of post-discharge care to be achieved, the patients and their families need to be involved in the care process and fully prepared for the post-discharge life. Therefore, if these two parties are not fully involved in the care process and prepared for post-discharge care, the readmissions will remain high.

Another cause of high heart failure readmission is uncoordinated post-discharge follow-ups and lack of post-discharge patient monitoring. Some healthcare providers lack proper frameworks of monitoring and facilitating a continuum of care after patients have been discharged (Lee, Yang, Hernandez, Steimle & Go, 2016). This means that after patients have been discharged, the only way they can be assess or they can communicate with their care providers is during the appointments. Some patients, especially those who have to travel from rural and underserved areas for specialized treatments, fail to honor their clinical appointments due to inconvenience and the expenses associated traveling to and from the hospital. Therefore, if there are any undesired changes and outcomes, patients are at risk of being readmitted due to the disease progression and distressing symptoms. Lack of appropriate and patient-centered post-discharge care has resulted in a high 30-day mortality rate among heart failure patients. In a study conducted by Faillace et al. (2018), it was discovered that out of all the heart failure deaths that were recorded during the study period, 48% of them occurred within 30 days after the patients had been discharged. Therefore, it is important for care providers to establish proper monitoring methods to maintain a continuum of care even after the patients have been discharged. In some healthcare centers, care delivery ends at discharge. Others make efforts, but their approaches to post-discharge care are ineffective. Therefore, identifying the challenges associated with the provision of post-discharge interventions and the consequences of ineffective will make healthcare providers look beyond just in-patient care. This study will also identify different approaches to post-discharge care provision and compare their effectiveness in the healthcare system. This way, healthcare providers will be able to choose the most preferable, affordable, and effective approaches to post-discharge care depending on their target populations.


Heart failure is associated with cardiovascular conditions such as hypertension and stroke. Patients suffering from heart failure require constant care and attention from care providers so as to ensure that vital parameters such as blood pressure are constantly kept under control. However, most care providers fail to maintain the continuum of care due to lack of proper frameworks to ensure that patients have access to necessary resources, support, timely healthcare services even after they have been discharged. This has, therefore, led to high 30-day heart failure readmission and mortality rate. The care providers need to adopt evidence-based interventions that will ensure that even after they have been discharged, patients receive necessary support during the recovery process, they have access to vital resources such as community-based health workers and clinics, and that they are constantly monitored throughout the recovery process for better outcomes.



Akande, S. (2017). Factors associated with heart failure readmissions from skilled nursing facilities. Interventional Cardiology09(01). doi: 10.4172/Interventional-cardiology.1000547

Centers for Disease Control and Prevention. (2020). Heart Failure. Retrieved 15 September 2020, from,estimated%20%2430.7%20billion%20in%202012.

Faillace, R., Yost, G., Chugh, Y., Adams, J., Verma, B., & Said, Z. et al. (2018). Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality? The American Journal Of Medicine131(2), 201.e9-201.e15. doi: 10.1016/j.amjmed.2017.09.007

Felix, H., Seaberg, B., Bursac, Z., Thostenson, J., & Stewart, M. (2015). Why Do Patients Keep Coming Back? Results of a Readmitted Patient Survey. Social Work In Health Care54(1), 1-15. doi: 10.1080/00981389.2014.966881

Gonçalves-Bradley, D., Lannin, N., Clemson, L., Cameron, I., & Shepperd, S. (2016). Discharge planning from hospital. Retrieved 15 September 2020, from,costs%20and%20improving%20patient%20outcomes.

Lee, K., Yang, J., Hernandez, A., Steimle, A., & Go, A. (2016). Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization. Medical Care54(4), 365-372. doi: 10.1097/mlr.0000000000000492

Nair,R., Lak, H., Hasan, S., & Babar, A. (2020). Reducing All-cause 30-day Hospital Readmission for Patients Presenting with Acute Heart Failure Exacerbations: A Quality Improvement Initiative.

O’Connor, C. (2017). High Heart Failure Readmission Rates. JACC: Heart Failure5(5), 393. doi: 10.1016/j.jchf.2017.03.011

Post Discharge Intervention to Decreased Hospital Readmission in Older Adults with Heart Failure

University approved list: The effectiveness of (Intervention) for (Elderly or population) With Heart Failure to Reduce Hospital Readmission.

Project Purpose: Reducing Hospital Readmission for Through Telemonitoring

With high numbers of hospital readmission among adults above the age of 65, there is a need to rethink post discharge care. In the United States, the number is approximately 6.2 million people with Heart Failure (HF) conditions. Between the years 2012 and 2030, heart failure prevalence is projected to be a risk to 46%, with 8 million adults having chronic heart conditions. According to the Centers for Disease Control and Prevention (CDC), heart failure contributed to 379,800 deaths in 2018, which is 13.4% of all deaths in the US (CDC, 2020). The project aims to compare the post-discharge nursing intervention of telemonitor and in-person home care in reducing the number of older adults being readmitted to the hospital. The project aims to give medical practitioners an insight into the most efficient method of taking care of patients at home while also reducing readmission risk.

Background and Significance

According to the CDC, the percentage of older adults above the age of 65, with heart failure conditions who get readmitted within 30 days is approximately 20%. After considering the in the US alone, 6.2 million people have the HF with projection predicting that the figure will have increased to 8 million by the year 2030 (O’Connor, 2017). Additionally, the number of deaths reported in the year 2018 as a result of HF comprised 13.4% of the total deaths that year (CDC, 2020). Thus, the heart is recognized among the leading causes of death in the US and worldwide. However, the most important task that the health care sector will have to take only is ensuring that those admitted to the hospital and discharged do not develop a complication that will require them to be readmitted back to the hospital (Felix, Seaberg, Bursac, Thostenson & Stewart, 2015). Thus, several interventions are needed to deal with the problem. However, the most critical is providing care to the patient even after being discharged from the hospital to ensure they follow prescriptions to the later.

The project primarily focuses on the need for older adults of the age of 65year and above regarding heart failure. The information from the project can also be modified to fit the criteria of other patients. In this case, the project concentrated on how older people with heart failure can be improved (Faillace et al., 2018). Specifically, the project tries to solve the problem of readmissions to the medical facility within 30 days of discharge. Thus, the project’s population is adults above the age of 65 years older with heart failure conditions who are at the risk of having heart failure.

Telemonitoring is one of the recently introduced techniques used to monitor the patient’s health while at home after discharge. The intervention’s fundamental medium is the use of the internet that has become accessible to every individual (Chaudhry et al., 2010). Thus, using this method, medical experts save on the cost of health on medical institutions. Given that nurses and doctors only require a computer and internet connection to give the patient services, they save on the cost of transportation and save on time. Thus, in terms of cutting on expenses, telemonitoring contributes more.

However, when it comes to analyzing matters beyond what the patient is willing to share, in-person home care intervention has an advantage. Telemonitoring home care intervention depends on the patients to give the medical expert or nurse information needed to come up with prescriptions and give proper advice (Gorodeski et al., 2020). However, the downside to depending on the patient’s information without examining them is that the data is unreliable, as most patients, unlike nurses, do not know what is essential to divulge (Chaudhry et al., 2010). Thus, with in-person home care intervention, the nurse or doctor can access the patient’s environment. However, they can also conduct physical examinations that help reconcile with the patient’s data. This intervention is slow and consumes a lot of time. With the number of patients increasing year-on-year, the existing workforce will be strained; hence, telemonitoring becomes not only an option but also a necessity.

Given that the percentage of patients who are discharged from the hospital and are readmitted within 30 days is 20%, the project’s outcome is to reduce that figure of readmissions by 20% (O’Connor, 2017). With the number of HF patients above the age of 65 years increasing each year, telemonitoring will be able to serve many of them in a very short amount of time as the time spent traveling from one home another is eliminated. Additionally, with the use of the teach-back method on patient s before discharge, they will be health literate enough to understand what is needed of them. The project will be conducted for six months from the time of implementation to the conclusion.

PICOT Formatter Clinical Project Question

This paper will respond the clinical questions in the PICOT format. In elderly ages 65 years and older with heart failure who recently discharged from the hospital to their homes (P), how effective is post-discharge nursing interventions using remote telemonitoring (I) when compared to on-site visitation by home care nurse ( C) in reducing hospital readmission rates within 30 days post-discharge (O) in 6 months period (T)?

The study population would be elderly patients ages 65 and older with heart failure who are newly discharged from the acute hospitals to their house. The nursing post-discharge intervention would be remote home telemonitoring. This study’s ideal group size would be 85 or more participants with a similar size control group who receive on-site visitation as their discharge nursing intervention. The outcome that is expected from the project is identifying the most effective method in reducing hospital readmission rates within 30 days post-discharge by 20 %. The time frame for this study would be six for months.



The American health care system has come under stress and pressure the number of people approaching the age of 65 is increasing. The older adults have a high prevalence rate to have chronic diseases like Heart Failure. With the increase in admission in the recent years, hospital readmission has risen thus calling for the intervention that will help lower the admission rates within 30 days of discharge (Chaudhry et al., 2010). One of the most popular being the use of in-person health care monitoring in which the nurse visits that patient at their homes. However, this method of intervention is time consuming and uneconomical considering the continuous surge in the number of cases every year (Faillace et al., 2018). Therefore, with technology advancement, the use of tele monitoring system for post-discharge patients appears to be cost effective. Additionally, tele monitoring save on time as more patients can be served within a short time. Thus, in monitoring the current situation, tele monitoring is more effective.





Chaudhry, S. I., Mattera, J. A., Curtis, J. P., Spertus, J. A., Herrin, J., Lin, Z., … & Krumholz, H. M. (2010). Telemonitoring in patients with heart failure. New England Journal of Medicine363(24), 2301-2309.

Faillace, R., Yost, G., Chugh, Y., Adams, J., Verma, B., & Said, Z. et al. (2018). Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality? The American Journal Of Medicine131(2), 201.e9-201.e15. doi: 10.1016/j.amjmed.2017.09.007

Felix, H., Seaberg, B., Bursac, Z., Thostenson, J., & Stewart, M. (2015). Why Do Patients Keep Coming Back? Results of a Readmitted Patient Survey. Social Work In Health Care54(1), 1-15. doi: 10.1080/00981389.2014.966881

Gorodeski, E. Z., Moennich, L. A., Riaz, H., Jehi, L., Young, J. B., & Tang, W. W. (2020). Virtual Versus In-Person Visits and Appointment No-Show Rates in Heart Failure Care Transitions. Circulation: Heart Failure, 13(8), e007119.O’Connor, C. (2017). High Heart Failure Readmission Rates. JACC: Heart Failure5(5), 393. doi: 10.1016/j.jchf.2017.03.011


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