The following article is part of The Clinical Advisor’s coverage from the 2018 American Association of Nurse Practitioners’ annual meeting in Denver. Our staff will be reporting live on original research, case studies, and professional outreach and advocacy news from leading NPs in various therapeutic areas. Check back for ongoing updates from AANP 2018. 

DENVER – The use of a simplified discharge tool, follow-up telephone calls, and care navigators can decrease the rate of readmissions for patients with congestive heart failure (CHF),1 according to research presented at the American Association of Nurse Practitioners 2018 National Conference.

The researcher reviewed the literature in order to find ways to improve the transition of care and readmission rates for patients with CHF in hospital and primary care settings. In the review, the researcher found 3 studies that looked at tools for improving transition of care.

A study by Balaban and colleagues used a discharge tool and telephone follow-up by a registered nurse.2 This led to improved follow-up, completion of requesting outpatient testing, and improved outcomes. In a study by in Occelli et al, a transition nurse paired with interventions decreased readmissions and emergency department visits.3 In a systematic review by Hand and Cunningham, follow-up phone calls to the patient were found to improve transition of care.4

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A simplified discharge tool paired with a follow-up telephone call 72 hours after discharge from a care navigator helped to reduce the rate of readmissions for patients with CHF. Seeing the patient 10 days after discharge in a primary care setting, early palliative care, home care management/education, consideration for home visits, evaluation of other readmission diagnoses, extended care facilities scorecards, and use of pharmacy technicians for medication may also help reduce readmission rates in this and other patient populations.

For more coverage of AANP 2018, click here.


  1. Elchert L. A road to improving transition of care: with a focus on CHF re-admissions. Presented at the American Association of Nurse Practitioners 2018 conference; June 26-July 1, 2018; Denver, CO.
  2. Balaban RB, Weissman JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;23(8):1228-1233.
  3. Occelli P, Touzet S, Rabilloud M, et al. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016;16:57.
  4. Hand KE, Cunningham RS. Telephone calls postdischarge from hospital to home: a literature review. Clin J Oncol Nurs. 2014;18(1):45-52.