Bridging the gap between hospital and home: a new model of care for reducing readmission rates in chronic heart failure

J Cardiovasc Nurs. 2011 Sep-Oct;26(5):368-76. doi: 10.1097/JCN.0b013e318202b15c.


Advanced cardiovascular interventions and an aging population contribute to the growing prevalence of patients with heart failure (HF). Improved medical management, while decreasing mortality, has increased morbidity and cost, with a majority of expense related to preventable hospitalizations. Evidence-based guidelines for discharge instruction, when successfully administered, reduce readmission rates in high-risk HF patients, leading to improved quality of life and economic savings. Unfortunately, effective delivery is complex and time consuming, placing a high demand on already overworked bedside nurses. Failure to provide complete discharge instructions results in nonadherence to treatment regimens and lack of essential follow-up, the most commonly identified reasons for acute HF exacerbations and readmissions. To improve quality of care, hospitals need to adopt a new model that incorporates delivery of intensive, 1-on-1 education to high-risk HF patients during the hospital stay with continuing support, guidance, and education throughout the transition from hospital to home. This can be achieved through implementation of a 2-tiered model that incorporates a risk-assessment tool with utilization of a HF nurse educator. The simple, evidence-based bedside screening tool will allow medical-surgical nurses to quickly identify and refer HF patients at high risk of readmission to a HF nurse educator. With an advanced degree and specialized training, the nurse educator is responsible for providing in-depth discharge teaching and bridging the gap from hospital to home. The end result is improved self-management, increased quality of life, reduced hospital admissions, and an associated decrease in societal costs of HF.

MeSH terms

  • Chronic Disease
  • Heart Failure / nursing*
  • Humans
  • Models, Theoretical
  • Patient Education as Topic*
  • Patient Readmission / statistics & numerical data*
  • Retrospective Studies