A nurse practitioner-led program aimed at reducing hospital readmission rates for veterans with heart failure (HF) successfully lowered rates and helped patients set at least 1 self-care goal, according to research published in the Journal of the American Association of Nurse Practitioners.

Elaine J. Charteris, DNP, ANP-C, CHFN, and colleagues at the Southern Arizona Veterans Administration Health Care System (SAVAHCS) established a quality improvement (QI) initiative with the goal of reducing 30-day all-cause readmissions for veterans with HF by 1% over an 8-week period. Though the outcome of the initiative fell short of this goal — readmission rates decreased by 0.2% by the end of the study period — Dr Charteris expressed confidence that readmission rates would continue to decrease provided the multidisciplinary HF clinic is sustained.

Prior to intervention, the all-cause 30-day readmission rate for over 5600 patients with HF at SAVAHCS discharged to home was 21.4%. Dr Charteris cited previous research that indicates healthcare costs for patients with HF amount to more than $39 billion annually,2 and stated that eliminating preventable readmissions could lower both costs and burden on patients.

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In 4 plan-do-study-act (PDSA) cycles that lasted for 2 weeks each, a core team that included 1 cardiology NP, 2 clinical pharmacists, and 1 dietician staffed a multidisciplinary HF clinic; in the second cycle, 2 cardiologists and 2 additional NPs joined the group.

During the first PDSA cycle, clinicians established the clinic dedicated specifically to recently discharged patients with HF. Patients were scheduled to visit the clinic within a 14-day window after discharge, as recommended by the American Heart Association and American College of Cardiology.3

A total of 33 patients were seen in the clinic by an NP for a 60-minute visit, during which the provider focused on patient engagement, education, and goal-setting. The patients then had a 15-minute visit with a dietician for a personalized nutritional consultation and a 15-minute visit with a pharmacist for medication reconciliation and education. While patients were seen by an NP or cardiologist 100% of the time, only 50% (n=16) saw a pharmacist and 26% (n=10) met with a dietician.

Patient satisfaction rates with the clinic were high, ranging between 83% and 100%. As the study progressed, changes were made to the patient engagement and goal setting processes. Overall, the patient engagement tool developed by Dr Charteris was used 84% of the time.

On average, patients set self-care goals 87% of the time, though patients seen by an NP (n=30) set goals more than 90% of the time. In the first PDSA cycle, patients were able to set at least 1 goal 31% of the time; however, by the third cycle, 78% of veterans set at least 1 self-care goal. In the final PDSA cycle, 100% of patients made at least 1 goal. 

By the end of the fourth PDSA cycle, patients seen in the clinic had a 30-day all-cause readmission rate of 21.21% compared with 21.42% at baseline.

Dr Charteris noted that this study is limited by a small sample cohort and inconsistent staffing at the clinic throughout the study period, but noted that efforts to reduce readmission rates for patients with HF are crucial to reducing mortality and improving quality of life.

“Strengths of this QI project were veteran-centeredness, timeliness of follow-up visits, ease of implementing shared clinics, and inexpensive engagement tools that can be easily replicated at other VA facilities,” she stated.


  1. Charteris EJ, Pounds B. A nurse practitioner-led effort to reduce 30-day heart failure readmissions. J Am Assoc Nurse Pract. 2020;32(11):738-744. doi:10.1097/JXX.0000000000000470
  2. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics-2018 update: A report from the American Heart Association. Circulation. 2018;137(12):e67-e492. doi:10.1161/CIR.0000000000000558
  3. Heidenreich PA, Fonarow GC, Breathett K, et al. 2020 ACC/AHA clinical performance and quality measures for adults with heart failure. Circulation. 2020;13(11):919-956. doi:10.1161/HCQ.0000000000000099