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Transitional Care Programs Improve Outcomes for Heart Failure Patients: An Integrative Review

Stamp, Kelly D. PhD, APRN, ANP-C; Machado, Monique A. RN, MSN, ANP-BC; Allen, Nancy A. PhD, ANP-BC

Journal of Cardiovascular Nursing: March/April 2014 - Volume 29 - Issue 2 - p 140–154
doi: 10.1097/JCN.0b013e31827db560

Background: Individuals with heart failure are frequently rehospitalized owing to a lack of knowledge concerning how to perform their self-care and when to inform their healthcare provider of worsening symptoms. Because there are an overwhelming number of hospital readmissions for individuals with heart failure, efforts are underway to discover how they can be supported and educated during their hospitalization and subsequently followed by a nurse after discharge for continued education and support.

Purpose: The purpose of this integrative review was to critically examine the interventions, quality of life, and readmission rates of individuals with heart failure who are enrolled in a transitional care program. The second aim was to examine the cost-effectiveness of nurse-led transitional care programs.

Conclusions: The results of this integrative review (n = 20) showed that transitional care programs for individuals with heart failure can increase a patient’s quality of life and decrease the number of readmissions and the overall cost of care. The types of interventions that were most successful in decreasing readmissions used home visits alone or in combination with telephone calls. There is a need for nurse researchers to address gaps in transitional care for heart failure patients by performing studies with larger randomized clinical trials and measuring outcomes such as readmissions at regular intervals over the study period.

Clinical Implications: The Patient Protection and Affordable Care Act will change reimbursement for heart failure readmissions and presents opportunities for healthcare teams to build transitional care programs for patients with conditions such as heart failure. This integrative review can be used to determine effective intervention strategies for transitional care programs and highlights the gaps in research. Healthcare teams that use these programs within their practice may increase continuity of care and quality of life and decrease readmissions and healthcare costs for individuals with heart failure.

Kelly D. Stamp, PhD, APRN, ANP-C Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

Monique A. Machado, RN, MSN, ANP-BC Adult Nurse Practitioner, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

Nancy A. Allen, PhD, ANP-BC Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

The authors have no funding or conflicts of interest to disclose.

Correspondence Kelly D. Stamp, PhD, APRN, ANP-C, William F. Connell School of Nursing, Boston College, 140 Commonwealth Ave, Cushing Hall 334F, Chestnut Hill, MA 02467 (

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins