Date of Award


Document Type


Degree Name

Doctor of Nursing Practice (DNP)

School Name

Donna and Allan Lansing School of Nursing and Health Sciences



Major Advisor

Barbara Jackson, PhD, RN



Heart failure readmissions are a common and costly issue. Poor transitions of care as patients move from one setting to another are thought to be a major contributor to this growing problem. For those patients discharged to skilled nursing facilities (SNFs), poor transitions can be especially problematic. Telephone follow-up by nurses is a cost effective intervention commonly used to improve communication and coordination of care, thought little is known about interventions directed at patients discharged to SNFs. The purpose of this review is to evaluate the evidence regarding nurse led telephone follow-up in the transition of care process and provide a foundation for future study of these interventions in the SNF population. Synthesis of evidence from an integrative review, four systematic reviews, and three clinical practice guidelines suggests telephone follow-up may aid in the reduction of readmissions but further study is needed to determine the most effective structure of a telephonic program.