A Supportive Heart Failure Care Program to Reduce Hospital Readmissions.

In the United States, heart failure (HF) is the leading reason for hospital readmissions, with 27% of Medicare recipients with HF being readmitted within 30 days The purpose of this quality improvement project was to decrease HF readmissions during their first 30 days of care with our home health agency. The Supportive Heart Failure Care education program was based on the results of a population assessment and included establishment of agency-wide best practices, nursing education sessions, and implementation of best practices focused on evidence-based self-management. After implementation of this project, the hospital readmission rate decreased from 32% to 21%. The nurses who completed the education sessions (N = 35) showed an increase in knowledge of 4.1% from pre-test scores. However, chart audits showed varying levels of documented practice in alignment with best practices. Although results of this project showed a small improvement in nurse knowledge and varied changes to documented practice, the overall project goal of decreasing hospital readmissions was achieved. Understanding individual and systems-level barriers to translating education to practice is needed to better meet the needs of home health nurses and the HF patients they serve.