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Home Healthcare Nurse:
Management Matters

A Clinical Pathway for Congestive Heart Failure

Hoskins, Lois M. PhD, RN, FAAN; Clark, Helene M. PhD, RN; Schroeder, Mary Ann DNSc, RNCS; Walton-Moss, Benita DNS, RNCS, FNP; Thiel, Sr.Linda DNSc, RNCS, FNP

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Author Information

Lois M. Hoskins, PhD, RN, FAAN, is Professor Emerita, School of Nursing, The Catholic University of America, Washington, DC where Helene M. Clark, PhD, RN, is an Assistant Professor, and Mary Ann Schroeder, DNSc, RNCS, is an Associate Professor, Retired.

Benita Walton-Moss, DNS, RNCS, FNP, is an Assistant Professor, School of Nursing, Johns Hopkins University, Baltimore, MD.

Sr. Linda Thiel, DNSc, RNCS, FNP, is Director of Health Services, Grand Rapids Dominicans, Grand Rapids, MI, and Clinical Adjunct Faculty, Kirkhof School of Nursing, Grand Valley State University, Allendale, MI.

Address for correspondence: Lois M. Hoskins, PhD, RN, FAAN, School of Nursing, The Catholic University of America, Cardinal Station, Washington, DC 20064; e-mail:

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Part II of a study that compared two groups of elderly home health patients with congestive heart failure (CHF) is presented. One group’s plan of care was guided by a clinical pathway while the other group’s was not. As described in the first part of the study (published last month), the rehospitalization rate in the group not on the clinical pathway was 22.9% versus 12.5% in the clinical pathway group, a 45% reduction. In this article the pathway is presented, intermediate patient outcomes are described, and selected variables are analyzed for their impact on rehospitalization.

Home healthcare was hard hit by the 1997 Balanced Budget Act, and with the Prospective Payment System (PPS) the premiere question is: Are cost containment and quality compatible? If cost control is imposed, will patient care suffer?

As described in the article, “Clinical Pathways Versus a Usual Plan of Care: What’s the Difference” in last month’s issue of HHN, patients with congestive heart failure (CHF) in the study who received care guided by the use of a clinical pathway had significantly lower hospital readmission rates than patients not on the pathway.

Use of a clinical pathway has been cited by many authors as a way to reduce costs through an inclusive and systematic approach to caring for patients with specific diagnoses. A reduction in the rate of hospitalization can be seen as not only cost effective but also as a quality indicator. Based on this study and other results of caring for patients with CHF at home with a clinical pathway, the answer to the compatibility issue is “yes, cost containment and quality are compatible.”

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Development of the CHF Clinical Pathway

Members of the Performance Improvement Department, composed of staff nurses of Adventist Home Health Services, developed the clinical pathway in 1997 (Adventist Home Health Services, 1997). The overall goals of the case-managed pathway were to reduce cost and disability to the patients in the community setting and to facilitate their optimal transition to self-care or to care by other informed caregivers.

The CHF pathway included specific interventions to be delivered by a multidisciplinary team over nine visits. The pathway incorporated guidelines for the management of heart failure cited by the Agency for Health Care Policy and Research (AHCPR) (Konstam, Dracup, & Baker, 1994). As shown in Figure 1, the nurse providing care initials the specified activities, and if any activity cannot be carried out the reason or variance is coded. It was proposed that the nine visits be spread out over a minimum of 6 weeks.

Figure 1
Figure 1
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Figure 1
Figure 1
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Patient Outcomes

Six patient outcomes were identified and were considered to be intermediate outcomes that are instrumental in reaching the end-result outcome, avoiding rehospitalization. The outcomes reflect self-care abilities of the patient and/or the patient with the caregiver’s assistance. The outcomes are that the patient is able to:

verbalize definition/causes of CHF and three reportable symptoms of exacerbation;

state two complications of CHF (consequences of noncompliance);

demonstrate medication compliance and verbalize understanding of medication action, dose, schedule, and side effects to report;

demonstrate tolerance to gradual activity increase and understanding of energy conservation techniques;

explain low sodium diet and adequate potassium intake; and

demonstrate safety precautions in use of oxygen (if ordered).

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Evaluation of the Outcomes

The six outcomes are identified as patient/caregiver goals and they are evaluated by the home health nurse as being “met,” “not met,” or “needs reinforcement.” If the goal is not met a variance code for the reason is specified, e.g. too sick, comorbid interference. The outcomes are summarized at the time of discharge (see Figure 2). The outcome forms are used by the performance improvement department to prepare quarterly reports that total the outcomes, whether they were met, the variance codes, and the average number of visits per payor type. These are presented for review and discussion by members of the department, nursing administrators, a hospital cardiac clinical specialist, and a member of the academic research team for the ongoing evaluation of the effectiveness of the case-managed system.

Figure 2
Figure 2
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Educational Materials

Educational materials to support the patients’ achievement of the outcomes are prepared as handouts. They are individualized to the patients during nursing visits and titles include:

* Congestive Heart Failure,

* Managing Your Medications,

* Energy Conservation: Pacing Your Home Activities,

* Guidelines for Exercising,

* Cardiac Risk Factors: Fact Sheet, and

* Oxygen Therapy.

A symptom log and telephone instructions were included (see Figure 3). Nursing clinical visit notes (see Figure 4) were also modified with the advent of the pathway. They are more standardized and the documentation is more objective than the previous forms used with the usual care group.

Figure 3
Figure 3
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Figure 4
Figure 4
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In our initial study (Hoskins, Walton-Moss, Clark, Schroeder, & Thiel, 1999) we collected data from 140 clinical records of patients with CHF receiving a usual plan of care (usual care) and identified predictors of rehospitalization. Afterward, a case-managed clinical pathway (pathway) was put in place and, using the same data collection methods, we reviewed 67 clinical records and compared the two groups. Our target outcome was the comparison of rehospitalization (all patients were referred to home care from the hospital) in the two groups after adjusting for risk factors. Part I of this series described the research design and results in greater detail. What is reported here are selected variables related to the pathway and the 67 patients whose care was guided by it.

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Demographic Profile of Patients in the Study

The 67 patients were all age 65 or older, on Medicare, and had a principal diagnosis of CHF. Eight of the patients were rehospitalized. Based on average values, several typical patient characters were noted:

* In most instances, the patient was female, 80 years of age, and widowed.

* Immediately preceding her current admission she had been hospitalized an average of 12 days.

* She was most likely White, and living with a family member other than her spouse.

* She considered herself her own primary caregiver.

* She had an average of three medical diagnoses and had nine medications prescribed.

* During her admission, the patient had received 14 skilled nurse visits, 19 home health aide visits, 1 visit from a social service worker, and 7 physical therapy visits.

* Her average number of home healthcare days for this episode was 34.

* She was likely to need assistance in bathing and in home management but was independent or needed little assistance in other activities of daily living.

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Rehospitalization Rate

Eight of the 67 patients (12.5%) were rehospitalized. In the usual care group 32 of 140 (22.9%) were rehospitalized. This amounts to a reduction of 45% for the group on the clinical pathway.

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CHF Medications

Guidelines for pharmacological treatment of CHF are advocated by more than one agency/association. The guidelines usually distinguish among the etiologies and severity of the disease.

The agency for Health Care Policy and Research (AHCPR) published guidelines for heart failure in 1994 (Konstam et al., 1994). More recently, the American College of Cardiology (ACC) and the American Heart Association (AHA) have updated guidelines for the management of heart failure. These guidelines recognize that different diseases and defects contribute to heart failure and that pharmacological management will differ accordingly (American College of Cardiology, 1999

Data available in the home care records did not include the etiology or classification of the heart failure, nor was there a severity rating available such as that described by the New York Heart Association. This classification categorizes heart failure as Grade 1 through 4 depending on the patient’s symptoms and functional status.

In this study 27 patients were given ACE inhibitors, 48 diuretics, and 38 digoxin, respectively. Thirty-five patients were receiving antianginal drugs, 19 were on beta-blockers, and 21 had calcium channel blockers prescribed. Less than 10 patients were given adrenergics or angiotensin II blockers.

With respect to outcomes, it has been shown that using an ACE inhibitor in the proper dosage can decrease the time to readmission rate of CHF patients (Civitarese & DeGregario, 1999; Luzier, et al., 1998). Potentially the use of ACE inhibitors may have decreased the readmission rate in these patients. Also, 12 patients were on a combination of ACEs, diuretics, and digoxin, and only one of the 12 was rehospitalized. This is one of the particular combinations of medications mentioned in the AHCPR guidelines.

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Outcomes of Care

The desired end-result outcome of care was discharge of the patient from home care to self-care, i.e., not to be rehospitalized. The six outcomes developed by the performance improvement department were considered to be intermediate outcomes reflecting knowledge and behaviors that would be instrumental in preventing rehospitalization. Table 1 presents the six outcomes, the number of patients in each of the three categories, and the variances cited for not meeting the desired goal. Outcome six, “Demonstrates safety precautions in the use of oxygen, if ordered,” involved only 16 patients and was not used.

Table 1
Table 1
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Forty-seven to 53 (78%) of the patients for whom data were available met one or more of the five designated pathway outcomes. Five to 12 patients needed further reinforcement of the activities necessary to achieve the outcome. Variances were not always reported; however, those that were most frequently cited were (impaired) cognitive status or having been hospitalized. Figure 5 illustrates the differences in outcomes between patients discharged to self-care/home versus those rehospitalized.

Figure 5
Figure 5
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Rehospitalized Patients

Of the eight patients who were rehospitalized, five could not demonstrate tolerance to gradual activity, three could not explain a low-sodium diet and potassium intake, three could not verbalize the causes of CHF and reportable symptoms of exacerbation, two could not verbalize complications of CHF (consequences of noncompliance), and one could not demonstrate medication compliance and understanding of medication actions and side effects. Three of the eight patients achieved all of the outcomes. The reasons for their hospitalizations were not given.

Outcomes as predictors. Using regression analysis the five outcomes explained 27% (p = 0.006) of the variance in rehospitalization in this group of patients. Of the five outcomes:

* the most important single factor contributing to the risk of rehospitalization was a declining ability to demonstrate tolerance to gradual activity increase,

* second in importance was the ability to state two complications of CHF (consequences of noncompliance), and

* the findings support these pathway outcomes as important predictors and goals to be achieved in preventing rehospitalization.

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Despite the small sample size, the results for the pathway group are significant:

* There was a 45% reduction in rehospitalization in the pathway group versus the usual care group.

* Only 1 of 12 patients receiving CHF medications as proposed by the guidelines was rehospitalized.

* The outcomes used in the clinical pathway predicted 27% of the variance in rehospitalization.

The direct and indirect costs of CHF in 2000 are estimated at $22.5 billion. This includes costs of home health and other medical durables estimated at $2.2 billion, and lost productivity and mortality attributed to CHF also at $2.2 billion (American Heart Association, 1999). A small reduction can reap large cost benefits.

Conversely, the number of skilled nurse visits exceeded those of the usual care group by 10.6% (usual care 12.18 and pathway 13.48, respectively). Skilled nurse visits also exceeded the nine visits allotted on the pathway. The extra visits were deemed necessary to reach pathway goals, but could be costly.

Quality of life was not a measure included in this study. However, the authors assume that most patients and their families would prefer to remain at home rather than return to the hospital.

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Use of Clinical Pathways

With PPS, cost will be based on the episode rather than visits. Pathways in use in the agency in this study are being modified and will be based on outcomes and the episode of care rather than visits. However, they will not jeopardize care for visits and cost (K. Burke, personal communication, September 13, 2000). For some situations, such as wound care, protocols are being developed to assist the nurse. Further use and testing of clinical pathways in home care is needed.

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Another strategy to maintain contact with patients and to continue monitoring while decreasing the number of visits is telehealth. Knox and Mischke (1999) used an automated telemanagement program—a computerized phone system—for patients with CHF to call in their daily weights and answer survey questions about their symptoms. Early warning signs and problems were identified and followed up. After 18 months, telemanagement participants’ compliance rate averaged 89.5% and hospitalization rates were 0.6/patient/year compared with the national benchmark of 1.7/pt/yr.

Dimmick, Mustaleski, Burgiss, and Welsh (2000) reported on a federally funded home telemedicine program in a rural area. They calculated potential savings of $49.33 per visit with a group of patients with chronic disease, three of whom had CHF. Cost savings were related to mileage and nurse drive time. Patients, caregivers, and providers expressed high levels of satisfaction.

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This study has shown improved outcomes with the use of a clinical pathway. However, under PPS additional ways for coordination among healthcare providers and patients need to be developed to ensure improved care beyond those focusing on the use of the pathway. One recommendation is the use of telehealth.

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The authors acknowledge the collaboration of Kathleen M. Burke, MS, RN, Coordinator of Clinical Services, Adventist Home Health Services, Silver Spring, MD.

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1. Adventist Home Health Services. (1997). Documents related to development of clinical pathway. Silver Spring, MD: Author.

2. American College of Cardiology. (1999). ACC/AHA practice guidelines: News release. Retrieved November 30, 2000 from the World Wide Web: http://www.acc. org/clinical/guidelines/news/hf.htm.

3. American Heart Association. (1999). 2000 Heart and Stroke Statistical Update. Dallas, TX: Author.

4. Civitarese, L. A., DeGregorio, N. (1999). Congestive heart failure clinical outcomes study in a private community medical group. Journal American Board of Family Practitioners, 12, 467–472.

5. Dimmick, S. L., Mustaleski, C., Burgiss, S. G., Welsh, T. (2000). A case study of benefits and potential savings in rural home telemedicine. Home Healthcare Nurse, 18 (3), 124–135.

6. Hoskins, L. M., Walton-Moss, B., Clark, H. M., Schroeder, M. A., Thiel, L. (1999). Predictors of hospital readmission among the elderly with congestive heart failure. Home Healthcare Nurse, 17 (6), 373–381.

7. Knox, D., Mischke, L. (1999). Implementing a congestive heart failure disease management program to decrease length of stay and cost. Journal of Cardiovascular Nursing, 14 (1), 55–74.

8. Konstam, M., Dracup, K., & Baker, D. (1994). Heart failure: Evaluation and care of patients with left-ventricular systolic dysfunction. Clinical Practice Guideline 11, Publication No. 94-0612. Rockville, MD: Agency for Health Care Policy and Research.

9. Luzier, A. B., Forrest, A., Adelman, M., Hawari, F., Schentag, J., Izzo, J.L. (1998). Impact of angiotensin-converting enzyme inhibitor underdosing in rehospitalization rates in congestive heart failure. The American Journal of Cardiology, 82 (4), 465–469.

© 2001 Lippincott Williams & Wilkins, Inc.