Enhancing Transitional Care Outcomes For High-Risk Heart Failure Patients: A Liaison Nurse–Led Quality Improvement Initiative

Abstract

Heart failure (HF) is a long-term illness that costs healthcare systems a lot of money because it leads to high rates of readmissions, treatment fragmentation, and bad outcomes. Liaison nurses are mostly responsible for making sure that care is passed on smoothly. There are still gaps in coordination, especially for patients who are at high risk of HF. This quality improvement (QI) program's goal is to make it easier for people from different fields to talk to each other. Also, a liaison nurse-led intervention should be put in place to make discharge processes more consistent and improve the flow of care. Using Lewin's Change Theory and the Model for Improvement. The main goals of the effort are to set up organized follow-up coordination after discharge, standardize communication channels, and plan discharge education. The clinical microsystem's baseline data showed that there was inconsistent follow-up within 7 days of discharge and a 28% readmission rate within 30 days. By using PDSA cycles and strategies that are backed by evidence. The initiative's goals are to cut down on remissions by 20% over six months and improve prompt follow-up by 85%. This study emphasized the implications for practice and leadership, alongside the problem's context and evidence synthesis. It also talked about how the intervention was designed, how possible it was, and what it meant. The program's main goals are to improve health quality and equity and to help nurses improve their liaison nursing skills.