Defense Date

7-17-2025

Graduation Date

Summer 8-1-2025

Submission Type

Dissertation/Thesis

Degree Name

Doctor of Nursing Practice (DNP)

Department

Doctor of Nursing Practice (DNP) Program

School

School of Nursing

Faculty Mentor

Dr. Frank Kosnosky

Keywords

heart failure, hospital readmissions, interactive home monitoring, remote patient monitoring, transitional care, multidisciplinary care, telehealth, social determinants of health

Abstract

Hospital readmissions are described as a situation in which a patient is admitted to a hospital within 30-days of being discharged from an earlier inpatient stay and is a critical indicator of care, contributing heavily to the rising healthcare costs in the United States. Heart failure is one of the leading contributors to 30-day hospital readmissions, prompting healthcare organizations to develop and implement policies aimed at reducing these occurrences. This program evaluation examined the effectiveness of the University of Virginia’s (UVA) Interactive Home Monitoring (IHM) program at reducing 30-day hospital readmission rates among patients diagnosed with heart failure (HF). Utilizing remote patient monitoring (RPM) through the IHM program in combination with multidisciplinary care, the program addresses barriers that occur during the transitional period associated with leaving the hospital such as medication adherence, clinical provider follow-up, and social determinants of health. This program evaluation was guided using Rogers' Diffusion of Innovation Theory and the program evaluation analyzed patient data collected from electronic health records and remote monitoring platforms. Among the 94 enrolled patients with heart failure (HF) during time of data collection, 8.5% were readmitted to the hospital within 30-days, suggesting short-term effectiveness. Common comorbidities found within the patient population examined include hypertension, coronary artery disease, and diabetes mellitus. Barriers that were identified to successful program intervention were identified and grouped as technical challenges and health literacy issues. Unexpected results showed that remote patient monitoring also facilitated early detection of non-heart failure-related medical concerns, which ultimately enhanced patient care. These program evaluation's findings reinforce the effectiveness and potential of IHM programs in reducing 30-day hospital readmissions as well as improving clinical outcomes among HF patients. Recommendations include enhancing patient-specific education based on disease process and health literacy, addressing technological barriers, and expanding support for complex social circumstances. Future research should look at results over a longer period of time and discuss potential broader applications for patients who suffer from other chronic illnesses. This evaluation supports the wider adoption of comprehensive, patient-centered remote monitoring strategies to optimize healthcare delivery and patient outcomes in HF management.

Language

English

Download
COinS