Supporting Heart Failure Patients Beyond Discharge: Who Makes the Difference in Readmissions? A Rapid Review
Document Type
Presentation
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Publication Date
4-8-2026
Abstract
Heart failure (HF) is a leading cause of hospitalization and readmission worldwide, affecting more than 64 million individuals globally. Approximately 20-25% of patients are readmitted with 30 days of discharge, often linked to gaps in transitional care including inadequate patient education, poor communication, and limited post-discharge follow up (Savarese et al., 2022). As healthcare systems shift toward value-based care, reducing avoidable hospitalizations is a growing priority. This rapid review synthesized evidence on nurse-led transitional care interventions and their effectiveness in reducing hospital readmissions among adults with heart failure. A structured, rapid review of PubMed and CINAHL initially yielded 467 records, after deduplication and screening, seven studies met inclusion criteria, including randomized controlled trials and meta-analyses spanning the United States, Japan, Brazil and Canada, and a multi-national context.
Nurse-led interventions included transitional care programs, home visits, telemonitoring, and structured patient education. Findings were mixed but generally favored nurse-led approaches. Multicomponent interventions incorporating ongoing follow-up, symptom monitoring, and care coordination demonstrated the strongest evidence of effectiveness. Telemonitoring reduces rehospitalization and improved patient engagement, while single component interventions such as discharge education alone were less effective. An analysis under the Hospital Readmissions Reduction Program found no significant relationship between excess readmission penalties and measured care quality, raising questions about readmission as a standalone quality metric (Pandey et al., 2016). Nurse-led interventions are most effective when they provide continuous, multicomponent support beyond hospital discharge. These findings support integration of nurse-led transitional care models to reduce heart failure readmissions and improve outcomes, while informing policy debates about how readmission quality metrices should be designed.
Recommended Citation
Jones, Tiffany, "Supporting Heart Failure Patients Beyond Discharge: Who Makes the Difference in Readmissions? A Rapid Review" (2026). Master of Science in Health Policy Capstone Presentations. Presentation 33.https://jdc.jefferson.edu/mshp/33
Language
English
Comments
Presentation: 24:21