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A Review: Discharge Navigation and Its Effect on Heart Failure Readmissions

Schell, Wendy RN, MSN, CCRN

doi: 10.1097/NCM.0000000000000040

Purpose and Objectives: The purpose of this literature review is to investigate the potential benefit of the discharge navigator, patient education, and discharge planning in prevention of hospital readmissions for heart failure as it relates to case management.

Primary Setting: Applicable to all health care sectors where case management is practiced.

Findings/Conclusions: In the United States, over 50% of hospitalized patients older than 65 years with congestive heart failure are readmitted within 6 months of their hospital discharge. The Patient Protection and Affordable Care Act, commonly called Obamacare, was signed into law in 2010 and effective 2012 the Centers for Medicare and Medicaid Services (CMS) began the Readmissions Reduction Program, which requires the CMS to reduce payments to inpatient prospective payment system hospitals with excess readmissions. An estimated total of 2,217 hospitals across the nation will be penalized a percentage of their base Medicare reimbursements. Provisions of the Affordable Care Act that increase hospital's financial accountability for preventable readmissions have made it imperative to identify interventions that reduce hospital readmissions for patients with heart failure. Current evidence suggests that improving transition of care through intense repetitive education reduces hospital readmissions for heart failure by:

  • enhancing the patient experience through effective communication and education,
  • ensuring accurate medication reconciliation and follow-up appointments are made, and
  • providing good hand-off communication to other care providers improving patient care.

Implications for Case Management Practice: Case managers are faced with an ever-changing health care climate, including the demands of hospital readmission prevention. Because of this, case managers are in a unique position to ensure that the patient has a good understanding of their disease, medications, and follow-up instructions. One of the most effective ways to accomplish this is to be sure that every patient is assessed for discharge planning purposes and receives specific and consistent education throughout the care continuum, including follow-up care.

Wendy Schell, RN, MSN, CCRN, is a practicing Critical Care Certified Registered Nurse in Camden, New Jersey. She, a practicing RN, has worked within Cardiology for over 25 years. She has held many positions within Cardiology including Coronary Care Unit (CCU) staff nurse, associate manager, CCU manager, Cardiology Educator, Cardiology Practice Discharge Coordinator, Cardiology Navigator for Heart Failure, and currently is practicing as the Director of the Structural Heart Program at Cooper University Hospital. She has lectured on various topics in the field of Cardiology Nursing such as Cardiac Assessment, Basic Pacing, Basic and Advanced Hemodynamics, Telemetry monitoring, and basic and advanced 12-lead ECG Interpretation to name a few. Wendy has developed and implemented a patient education program for the heart failure population in effort to decrease the readmission rates within the institution. Wendy has just completed her Masters education through Rutgers University in Adult Gerontology Acute Care.

Address correspondence to Wendy Schell, RN, MSN, CCRN, Structural Heart Program Director, Cooper University Hospital Cardiology, One Cooper Plaza, Camden, NJ 08103 (

The author reports no conflicts of interest.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.