DNP Scholarly Projects


The American Heart Association (AHA) and Heart Failure Society of America’s (HFSA) guideline for Management of Heart Failure in Skilled Nursing Facilities acknowledged poor communication from hospitals to skilled nursing facilities (SNF) as a barrier to optimal heart failure (HF) management. The purpose of this pilot study was to improve adherence to guideline directed HF care in SNFs through enhanced communication between hospital HF specialists and providers at SNFs. The project leader designed a guideline driven provider-to-provider HF handoff tool. Twenty-one patient discharges were evaluated in the study. Follow up phone calls were made to SNF staff nurse within 48 hours of hospital discharge to determine adherence to guideline directed HF care. A mixed methodology approach was used to evaluate qualitative and quantitative data. The transition of care and communication process between hospital HF specialists and providers at SNFs was evaluated using Donabedian’s Structure Process and Outcomes Model. Quantitative and qualitative inferential statistical analysis was used to determine whether or not the HF handoff tool had an effect on adherence to guideline directed HF care in SNFs. Chi-square analysis determined there was no statistically significant difference between adherence to guideline directed HF care in SNFs and the use of a HF specific handoff tool. However, there was a statistically significant difference in adherence to 2-liter fluid restriction (p=.011) and daily weights (p=.025) for patients who were discharged to a SNF with a completed discharge summary. Furthermore, follow up phone calls made to SNFs resulted in a reduction of 22 HF order-transcription errors. None of the patients in the study were readmitted to the discharging hospital within 30 days. Future research should be conducted with a larger sample size to evaluate the impact of follow up phone calls, standardized HF discharge DEVELOPING A GUIDELINE 5 summaries, and collaboration with multidisciplinary HF clinics on outcomes for HF patients who are discharged to SNFs.



First Advisor

Dr. Linda Wofford

Scholarly Project Team Member

Dr. Tracy Johnson

Scholarly Project Team Member

Dr. Mark Aaron

Scholarly Project Team Member

Dr. Douglas Pearce

Scholarly Project Team Member

Joseph M. Price, Ph.D.


Nursing, School of


Health Sciences & Nursing, Gordon E. Inman College of

Document Type

Scholarly Project


Doctorate of Nursing Practice (DNP)

Degree Level


Degree Grantor

Belmont University


Heart Failure; Skilled Nursing Facility; Nursing Home; Transition of Care; Guideline

Included in

Nursing Commons