Abstract
Background: Congestive heart failure is one of the leading causes of hospital admissions in adults greater than 65 years old and costs the United States 32 billion dollars annually (Center for Disease Control- Heart Failure Fact Sheet, 2013).|Purpose: The purpose of this DNP scholarly project is to develop and evaluate an individualized program that will incorporate patient knowledge of CHF and improve the process from discharge to first outpatient appointment.|Design and Methods: The setting of the study was a primary care clinic located in a rural critical access hospital in Iowa. Telephone calls were placed within 72 hours post discharge following a script based on one written by the American Heart Association. Providers completed a survey at the end of the study regarding sustainability of the form.|Sample: Out of eleven providers only six cooperated with filling out the survey. Twenty-two people were admitted for heart failure during the study time period. The total number of participants that met inclusion criteria was 16 over the 12-week period from September through November.|Results: Four readmissions occurred within thirty days of discharge, two of them passed away. Four providers agreed they were satisfied with the telephone script and no one was dissatisfied. Three people found the form easy to use, found that the script provided additional info that they may use during an appointment, and that the script improved efficacy of patient appointments.|Conclusion: Although the sample size was relatively small and the outcomes could not necessarily be correlated with the implementation of the script the positive effects for the hospital were high and the process was accepted positively.