Evaluation of the Transitional Care Process Post-Discharge in the VA of Southern Nevada

Abstract

According to the U.S. Department of Health & Human Services (2015) 5.7 million people living in the United States have been diagnosed with heart failure. During the time frame between January 1, 2017 – June 30, 2017, there were a total of 1,972 patients receiving care from the VA of Southern Nevada that were diagnosed with congestive heart failure (CHF). Objective: The purpose of this quality improvement project is to evaluate the utilization and impact of the VA of Southern Nevada Transitional Care Program for patients admitted with CHF to improve hospital readmission rates and health outcomes. Method: The design of this DNP project included conducting a retrospective chart review to better understand participants, program follow-up, and identify the impact of primary care follow-up post hospital discharge on 30-day readmission rates within the VA Medical Center in Southern Nevada. Results: During the time frame between January 1, 2017 – June 30, 2017, 212 patients were admitted with CHF as part of their admission diagnosis, with 99 of these patients admitted with a primary diagnosis of CHF. Seventeen of these 99 patients with a primary diagnosis of CHF were readmitted in the VA of Southern Nevada within 30 days. Out of 17 patients, only nine patients were contacted within 48 hours of hospital discharge and one was seen by the PCP within two weeks of hospital discharge. Conclusions and Recommendations: There are significant gaps in the post discharge process that can be addressed and corrected with various modifications in the discharge and transitional care process, including incorporating a transitional care APRN role, telehealth, CHF clinic, and hospice referrals.