Summer 2022

Document Type

Scholarly Project


College of Nursing

First Advisor

Sabra Custer


Adult patients diagnosed with congestive heart failure suffer from high hospitalization rates, recurrent readmissions, decreased quality of life, increased healthcare expenditures, and increased mortality. This project aimed to determine if individualized coaching plans based on patients’ activation scores impacted emergency room visits and hospital readmissions. A pretest-posttest design was used. The 13-item Patient Activation Measure® (PAM®) tool was administered before and after completing 30-day individualized coaching. Seventy-five participants were recruited from referrals to the outpatient Continuum Case Management (CCM) program. Inclusion criteria included English-speaking adult patients diagnosed with congestive heart failure 18 years of age. The intervention consisted of individualized coaching administered by the CCM registered nurse and community workers based on patients’ initial activation scores. Chart reviews were conducted to determine if 30- and 90-day emergency room (ER) visits and hospital readmissions were impacted. These data were compared to the prior six-month data for emergency room visits and readmissions of heart failure patients enrolled in the CCM program. Pre and post-intervention activation levels were compared to determine the impact of individualized coaching compared to standard care. Individualized patient-centered care can reduce hospital readmissions and emergency room visits, improve quality of life, and decrease healthcare expenditures.


© 2022, Jessica Marie Thomas

Included in

Nursing Commons