` ASystematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure Jason T. Slyer DNP, RN, FNP-BC, CHFN, Catherine M. Concert DNP, RN, FNP-BC, CGRN, Anny M. Eusebio DNP, RN, FNP-BC, Margaret E. Rogers DNP, RN, FNP-BC and Joanne Singleton PhD, RN, FNP-BC, FNAP JBI Library of Systematic Reviews. 2011;9(15): , Pace University, College of Health Professions, Lienhard School of Nursing  Objective 1.Hospital compare, a quality tool provided by Medicare [Internet] U. S. Department of Health & Human Services, Available from: 2.Patient protections and affordable care act [Internet] Association of American Medical Colleges, Available from: 3.Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society. 2004;52: Boult C, Karm L, Groves C. Improving chronic care: The "Guided Care" model. The Permanent Journal 12:5054, Available from: 5.Coleman E, Smith J, Frank J, Min S, Parry C, Kramer A. Preparing patient and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatric Society. 2004;52:  Meta-analysis  Description of included studies The objective is to identify the best available evidence on the effectiveness of nurse coordinated transitioning of care between hospital and home on all cause hospital readmission rates in adult patients after a hospitalization for heart failure.  Methods The search strategy aimed to find both published and unpublished studies in the English language from January 1975 through July A search of MEDLINE, CINAHL, PsycINFO, Healthsource Nursing/academic edition, EMBASE, and the Cochrane Library, was conducted followed by a reference list search of relevant studies and a search of the grey literature. Key words: heart failure, readmission, transitional care, transition, disease management, case management, multidisciplinary care, patient discharge, discharge planning, patient care planning, care coordination, after care, guided care, hospital to home. Inclusion criteria: Randomized controlled trials that evaluated the effect of nurse coordinated transitioning of care from hospital to home in adult patients hospitalized with heart failure on readmission rates. The outcome was defined as hospital readmissions for all causes following an initial admission for heart failure. Data collection and analysis: Studies selected for retrieval were critically evaluated by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data were extracted and analyzed using the JBI- MAStARI program.  Background Readmission rates for patients with heart failure are a major concern for hospitals worldwide. The current readmission rate for patients with heart failure is 24.8% nationally. 1 Reduced reimbursement for heart failure readmissions will begin in 2012 as part of the Affordable Care Act. 2 Transition strategies have been focusing on the importance of patient education and a structured care plan to reduce readmission rates. The use of transitioning of care plans is believed to improve medication reconciliation, communication, patient education, and follow-up. 3-5 To date, the evidence has not been systematically evaluated to support the effectiveness of a nurse coordinated transitioning of care for patients with heart failure in reducing readmission rates..  Conclusion Reduced readmissions occur when transitioning of care interventions are carried out by a heart failure trained nurse who conducts at least one home visit and follows the patient at least weekly for a minimum of 30 days post discharge with either additional home visits or telephone contact.  Discussion Implications for practice: This review supports the development of a nurse coordinated transitioning of care plan which will require improvements in communication, in addition to changes in health policy and payment systems that align incentives and performance measures in caring for patients with heart failure. Implications for research: Future research should evaluate the effect of the intensity and duration of transitioning of care interventions on readmission rates in a large randomized control trial on an adult population with heart failure to determine the ideal frequency and duration of the post discharge interventions. Pace University, New York, NY; New Jersey Center for Evidence Based Practice at the University of Medicine and Dentistry of New Jersey.                                                                                            Results A total of 16 randomized controlled studies were included. Ten of the 16 studies included in the review show that a nurse led transitioning of care intervention can reduce the rate of readmission for patients with heart failure. Interventions utilizing home visits, or home visits coupled with telephone follow-up, show a more favorable reduction in readmission rates, than those intervention utilizing telephone follow-up alone.  References  Acknowledgements