The Role of the Nurse Navigator: Reducing 30-Day Readmissions?

The aim of this study is to compare readmission rates for patients who transition home from the hospital
under the care of the Heart Failure Nurse Navigator (HFNN) with patients who receive usual home
health care. Heart failure (HF) accounts for 20% of all hospital admissions and is the most common
diagnosis associated with a 30-day readmission of Medicare patients. Nationally, 24.7% of patients
with HF are readmitted within 30 days. The AHA and ACCF recognize a critical need for evidence
identifying best processes of care in transition from hospital to home. The comprehensive NN role not
only teaches the patient to adapt to the prescribed medical protocol, but also provides connectedness
and relationship. Home health nurses taught to perform the role of a HFNN may improve coordination
of post-hospital care and patient outcomes. The research design will be sequential mixedmethod.
Phase I will be a quantitative, quasi-experimental randomized study of the effect of HFNN on
30-day readmissions. Pre- and post-testing for HF self-care knowledge and quality-of-life will be
analyzed by repeated ANOVA. Independent T-tests will compare readmission rates between groups.
Phase II will be a qualitative study of transitioning home under the care of the HFNN. Intervention
patients will be invited to focus groups, and their responses to semi-structured questions will be coded
using conventional content analysis. It is hoped that the quantitative portion of the study will
demonstrate that the HFNN intervention will keep more patients out of the hospital for at least 30 days
and improve the HF self-care knowledge and quality of life. The qualitative portion may uncover
unknown elements of the HFNN/patient dynamic, as well as themes helpful in formulating further
questions about care of the patient with HF.