Document Type

Dissertation - Open Access

Award Date


Degree Name

Doctor of Philosophy (PhD)

Department / School

Graduate Nursing

First Advisor

Heidi Mennenga


Follow-up, Heart Failure, Nursing, RE-AIM Framework, Readmissions


Follow-up care is essential when trying to avoid readmissions for patients who have recently been discharged from a healthcare facility. As evidenced by the literature, multiple strategies have been implemented to help manage the care of heart failure patients; however, readmissions continue to be higher than desired, which implies the current strategies utilized should be reviewed and revised. It is important to evaluate the effectiveness of methods when providing follow-up care that prevents readmissions and is also beneficial and convenient for the patient. The qualitative case study explored a heart failure follow-up protocol completed by a registered nurse using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework. Two patients were followed to gain an understanding of their thoughts on the protocol and opportunities to enhance the protocol. This includes education on heart failure, medications, and signs and symptoms of exacerbations. The information gained from the follow-up phone calls and the patient satisfaction survey allowed the researcher to discover the benefits of the protocol, while investigating ways to improve the protocol.

Library of Congress Subject Headings

Heart failure -- Patients.
Postoperative care -- Evaluation.
Patient satisfaction.
Patient education.
Nurse and patient.



Number of Pages



South Dakota State University

Included in

Nursing Commons



Rights Statement

In Copyright