Abstract
Chronic heart failure (CHF) remains a leading driver of unplanned hospital readmissions, posing substantial clinical and economic burdens on modern healthcare systems. Advanced practice nursing interventions, particularly those led by Clinical Nurse Specialists (CNS), have emerged as promising strategies to bridge inpatient discharge and outpatient continuity. This comparative observational study evaluated the effectiveness of a dedicated CNS-led transitional care model versus standard post-discharge care in reducing 30-day and 90-day readmission rates among adult patients hospitalized for acute decompensated heart failure. A total of 428 patients admitted to a tertiary academic medical center were enrolled and followed across two distinct cohorts: standard discharge care (n = 214) and CNS-led transitional management (n = 214). The primary endpoint was 30-day all-cause hospital readmission, with secondary endpoints including 90-day heart failure-specific readmissions, self-care competence measured via the Self-Care of Heart Failure Index (SCHFI), and 90-day mortality. Patients receiving CNS-led transitional care demonstrated a statistically significant reduction in 30-day all-cause readmissions compared to the standard care group (14.5% vs. 24.8%; adjusted OR = 0.51, 95% CI: 0.31–0.84, p = 0.008). Significant improvements were also noted in 90-day HF-specific readmissions (18.2% vs. 29.4%, p = 0.006) and SCHFI self-care maintenance scores (p < 0.001). These findings underscore the vital role of Clinical Nurse Specialists in optimizing discharge readiness, enhancing self-efficacy, and mitigating high-frequency healthcare utilization in complex cardiovascular populations.
