Hospital Readmission Prevention: Study Design


The problem of high readmission rates among patients with chronic heart failure (CHF) is a pressing issue in modern nursing practice. In order to change the statistics for the better, an intervention is required to be carried out using a telemonitoring system or home services. The application of this method of work may allow achieving improvement in patient outcomes and reducing the level of readmissions.

Change Model Overview

For intervention, the ACE Star model will be used as a basis. It includes such components as scope definition, evidence, translation, integration, and recommendations. Professional nurses can resort to using this model in order to carry out the necessary research gradually and implement relevant practices reasonably. The use of this technique is fundamental for the subsequent work on the problem of readmissions among patients with CHF.

Define the Scope of the EBP

The problem of the high readmission rate among patients with CHF is a significant challenge for junior medical personnel. The need to provide comprehensive care involves persistent complications caused by low recovery outcomes. According to Martin, Anderson, Vincenzo, and Zai (2017), “adults with CHF represent 14% of the Medicare population” (p. 207). On a broader scale, this issue adversely affects the reputation of medical institutions.


In order to implement a proposed care plan successfully, a team of professionals is required to work together. A supervising cardiologist will oversee the target group of patients, and three registered nurses will assess well-being indicators and the outcomes of care provided. Also, the help of a technical employee is needed to monitor the uninterrupted operation of the equipment and to fix it if necessary.

Determine Responsibility of Team Members

The necessity to engage selected specialists is the need for the distribution of responsibilities. A supervising cardiologist is an accredited professional who can evaluate the results of the intervention competently. Junior medical personnel is responsible for data collection and overall monitoring. The role of technical work is to ensure the stable operation of all the components and not to allow equipment to break down.


As additional evidence to support the intervention, relevant materials are found. Current statistics are evaluated, and studies by other authors are analyzed. Clinical cases were found to provide an opportunity to assess the compliance of the applied technique concerning the described issue. The strength of this research is the fact that the relevance of the problem is confirmed in the academic literature, and justifications are collected from credible sources.

Summarize the Evidence

According to Leppin et al. (2014), nurse-directed interventions and exercise programs form the majority of studies related to increasing readmission rates. As O’Connor et al. (2016) remark, the technique of telemonitoring may have a profound impact as a proposal. According to Martin et al. (2017), the program described “substantially reduces both all-cause and cardiovascular readmission rates” (p. 208). Finally, Thomason, Hawkins, Perkins, Hamilton, and Nelson (2015) argue that the difference in readmission levels in patients using a telemonitoring technique and those who did not use it was 10% and 21%, respectively (p. 20).

Develop Recommendations for Change Based on Evidence

Based on the evidence presented, the introduction of a telemonitoring system to reduce readmissions in patients with CHF is reasonable and necessary. The application of this method of work may allow improving patient outcomes and achieving a decrease in the number of repeated applications. The insufficiently extended base for these interventions supplements the need for activities in this direction to obtain significant positive results.


Action Plan

To realize the stated research objectives, a team of specialists should be selected. Further, two target groups of patients with an appropriate health problem should be collected. The implementation time is thirty days, and it is assumed that during this period of work, telemonitoring will be able to justify itself. The evaluation will be carried out by qualified specialists, and the data obtained will be displayed in a statistical ratio.

Process, Outcomes Evaluation, and Reporting

As desired outcomes, information should be obtained about the fact that participants from the group with care based on telemonitoring demonstrate a lower level of readmission than those who did not receive such care. The results will be evaluated by specialists, and the data will be measured in accordance with the planned statistical analysis. The information will be transferred to the key stakeholders personally and via e-mail.

Identify Next Steps

On a larger scale, the work plan is supposed to be disseminated among other healthcare institutions. This project will be applicable to different units and facilities. To ensure consistency in the use of the presented algorithm, the data on the success of the intervention can be published in academic sources so that as many people as possible could know about the merits of this method.

Disseminate Findings

Within the organization, the findings of the study will be disseminated at the general staff meeting, including both senior and junior staff. Outside the clinic, information can be transferred to the representatives of other medical institutions. Also, this research can be published in print and online media to popularize the results of the work done and to draw the attention of stakeholders to the problem presented.


Reducing the level of readmission among patients with CHF by telemonitoring can be achieved through a competent intervention using the ACE Star model. The evidence is collected from credible sources, and the existence of the problem is proven. The scope of work is defined, and performers are selected based on their roles. The methodology is supported by the review of the academic literature. Implementation in practice may be achieved by working with two target groups and comparing the results obtained. To maintain this plan, information can be distributed among other medical professionals to popularize the results.


Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K.,… Montori, V. M. (2014). Preventing 30-day hospital readmissions. JAMA Internal Medicine, 174(7), 1095-1107. Web.

Martin, S., Anderson, B., Vincenzo, J. L., & Zai, S. Y. (2017). A retrospective comparison of home telehealth and nursing care with or without rehabilitation therapy on rehospitalization rates of individuals with heart failure. Journal of Cardiopulmonary Rehabilitation and Prevention, 37(3), 207-213. Web.

O’Connor, M., Dempsey, M., Huffenberger, A., Jost, S., Flynn, D., Norris, A., & Asdornwised, U. (2016). Using telehealth to reduce all-cause 30-day hospital readmissions among heart failure patients receiving skilled home health services. Applied Clinical Informatics, 7(02), 238-247. Web.

Thomason, T. R., Hawkins, S. Y., Perkins, K. E., Hamilton, E., & Nelson, B. (2015). Home telehealth and hospital readmissions: A retrospective OASIS-C data analysis. Home Healthcare Now, 33(1), 20-26. Web.