Background: The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%. Problem Statement: Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices. Methods: Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team. Outcomes: The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%. Implications for Practice: Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.
- advanced practice nurses
- evaluation and quality improvement program
- heart assist devices
- transitional programs
ASJC Scopus subject areas