Breaking the Readmission Cycle: A Systems Approach to Heart Failure Care

Hospital readmissions for heart failure are costly, common, and often preventable — but they reveal more about system failures than individual patient choices, exposing gaps in transitional care. This presentation introduces an evidence-informed transitional care model, led by nurses and designed through a systems science lens, to reimagine the discharge process as a system-wide redesign. The model highlights practical strategies to reduce readmissions, reduce costs, improve patient outcomes, and strengthen health system resilience by combining evidence-based nursing practices with systems thinking. Attendees will learn how frontline leadership and systems-based frameworks can align to deliver sustainable, measurable improvements to transitional care and quality improvements.

Explain why traditional discharge processes fall short and how nurse-led transitional care changes outcomes

Describe how systems-based approaches can make care transitions more reliable, cost-effective, and patient-centered.

Apply a practical framework to strengthen transitional care in their own setting, improving patient outcomes and reducing readmissions.