Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Marie VanderKooi, DNP, MSN, RN-BC

Second Advisor

Sandra Spoelstra, PhD, RN, FGSA, FAAN

Third Advisor

Kim Doherty, MSN, RN


Heart failure costs the United States 31 billion dollars each year, with much of those costs attributed to hospital admissions. Coordinating care across the health care continuum is a critical factor in improving heart failure care and reducing readmissions. An organizational assessment was conducted using the Burke and Litwin Causal Model of Organizational Performance and Change. The quality improvement project implemented a longitudinal plan of care (LPOC) across 10 hospitals and numerous ambulatory care sites at a large Midwestern health organization. Nurse care managers (NCMs) were the focus of this project due to their high-level of involvement in care coordination. Kotter’s Eight Step Change Model was used to guide implementation. Key implementation strategies included creating a steering committee, involving end users in LPOC design and testing, auditing and providing feedback to end users, and planning for optimization. Due to a delayed go-live date, post-implementation hospital readmission rates were not available at publication. No significant differences were found in staff perception of heart failure care coordination (pre to post implementation). However, NCMs communication of key patient elements in ambulatory settings were lower than NCMs in inpatient settings. LPOC adoption rate was 48% at five weeks post-implementation. LPOC implementation should include examining care coordination to contribute to the limited literature on LPOC use in practice and the effect of LPOC use on coordination of care for heart failure patients across the health care continuum.