Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2021


Doctor of Nursing Practice (DNP)

Primary Advisor

Dr. Joyce Knestrick, PhD, FNP-BC, FAANP, FAAN; Dr. Julie Britton DNP, RNBC, GCNS-BC, FGNLA


heart failure, skilled nursing facility, management, rehospitalization, nursing knowledge, Nurse Practitioner


Background: Reducing heart failure hospital readmissions remains a priority for health systems and is a marker of quality for the Center for Medicare and Medicaid Services (CMS). Heart Failure is the most common cause of U.S. hospital admissions and an effective management program in the nursing home setting is crucial for quality and outcomes.

Purpose: The purpose of this project was to implement and evaluate a Nurse Practitioner/Physician supported heart failure management program in a skilled nursing facility that is able to be incorporated into facility staff workflow, enhances nursing staff knowledge of heart failure, improves identification of patients with a heart failure diagnosis, and reduces facility hospitalization rates over a three-month period of time.

Methods: This was an evidence informed practice implementation and evaluation project that focused on all patients with a diagnosis of heart failure in a suburban skilled nursing facility. Quantitative data was obtained by using the Nurses Knowledge of Heart Failure survey and rehospitalization data was obtained from the practice site.

Results: Eighteen patients were followed by the program. All had timely identification,16.66% experienced a change of condition that triggered medical provider follow up and none had a heart failure related hospitalization. Six nursing staff completed the pretest (mean, [SD], 78.33, [13.29]) and posttest (86.66, [10.80]) and demonstrated a positive relationship between program implementation and nurses’ knowledge.

Conclusion: Implementation of a heart failure management program is associated with timely identification of patients, improved nursing knowledge, and timely intervention during changes in condition.

Open Access


Included in

Nursing Commons



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