Practice Project: Reducing 30-Day readmissions of adult heart failure patients using the Transitional Care Model
DNP Practice Project Education Training
About Lorena Smith, RN, BSN, MSN-L
Lorena Smith is a registered nurse with over 22 years of experience in healthcare Lorena graduated with an ADN from Scottsdale Community College, BSN from Grand Canyon University and MSN-L from Grand Canyon University.
With a background in critical care, she has worked in various areas such as the ICU, OR and the Emergency Department, where she entered into leadership as a Senior Manager. Continuing in leadership, Lorena has enjoyed past positions as the Director of Education, Director of Clinical Education/Acute Care Informatics, Director of Simulation and currently serves as the Dean of the BSN Program for Brookline College in Phoenix, Arizona.
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With an insatiable love of learning, Lorena entered into the DNP program at Chamberlain University where she currently attends and is slated to graduate in October 2025.
The DNP Practice Project
Reducing 30-Day readmissions of adult heart failure patients using the Transitional Care Model
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The purpose of the doctoral practice project is to improve the heart failure patient’s quality of life and outcomes by implementing the evidence-based Transitional Care Model and evaluate its efficacy in reducing 30-day readmissions. The measurable objectives of the project supporting the aim will be to (a) ensure inpatient nurses complete EHR medication reconciliation for HF patients before discharge, (b) ensure inpatient nurses provide patient education to HF patients, (c) case management nurses implement follow-up calls to HF patients within seven days of discharge (Kripalani et al., 2019; Martin et al., 2025; Morkisch et al., 2020; Nair et al., 2020).