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Journal of Cardiovascular Nursing:
doi: 10.1097/JCN.0b013e31827db560

Transitional Care Programs Improve Outcomes for Heart Failure Patients: An Integrative Review

Stamp, Kelly D. PhD, APRN, ANP-C; Machado, Monique A. RN, MSN, ANP-BC; Allen, Nancy A. PhD, ANP-BC

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Author Information

Kelly D. Stamp, PhD, APRN, ANP-C Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

Monique A. Machado, RN, MSN, ANP-BC Adult Nurse Practitioner, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

Nancy A. Allen, PhD, ANP-BC Assistant Professor, William F. Connell School of Nursing, Boston College, Chestnut Hill, Massachusetts.

The authors have no funding or conflicts of interest to disclose.

Correspondence Kelly D. Stamp, PhD, APRN, ANP-C, William F. Connell School of Nursing, Boston College, 140 Commonwealth Ave, Cushing Hall 334F, Chestnut Hill, MA 02467 (

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Background: Individuals with heart failure are frequently rehospitalized owing to a lack of knowledge concerning how to perform their self-care and when to inform their healthcare provider of worsening symptoms. Because there are an overwhelming number of hospital readmissions for individuals with heart failure, efforts are underway to discover how they can be supported and educated during their hospitalization and subsequently followed by a nurse after discharge for continued education and support.

Purpose: The purpose of this integrative review was to critically examine the interventions, quality of life, and readmission rates of individuals with heart failure who are enrolled in a transitional care program. The second aim was to examine the cost-effectiveness of nurse-led transitional care programs.

Conclusions: The results of this integrative review (n = 20) showed that transitional care programs for individuals with heart failure can increase a patient’s quality of life and decrease the number of readmissions and the overall cost of care. The types of interventions that were most successful in decreasing readmissions used home visits alone or in combination with telephone calls. There is a need for nurse researchers to address gaps in transitional care for heart failure patients by performing studies with larger randomized clinical trials and measuring outcomes such as readmissions at regular intervals over the study period.

Clinical Implications: The Patient Protection and Affordable Care Act will change reimbursement for heart failure readmissions and presents opportunities for healthcare teams to build transitional care programs for patients with conditions such as heart failure. This integrative review can be used to determine effective intervention strategies for transitional care programs and highlights the gaps in research. Healthcare teams that use these programs within their practice may increase continuity of care and quality of life and decrease readmissions and healthcare costs for individuals with heart failure.

Coronary heart disease (CHD) is the number 1 killer of individuals worldwide and is the most costly medical condition in the United States.1,2 Coronary heart disease is defined as a narrowing of the small vessels that supply blood and oxygen to the heart. Components of CHD, such as hypertension, previous myocardial infarction, history of valvular insufficiency, diabetes, and obesity, place individuals at risk for heart failure (HF).3 Heart failure is a complex, chronic condition in which the heart muscle becomes weakened and loses its ability to pump oxygenated blood to meet the body’s metabolic needs.4 It affects about 5.8 million individuals, with associated health expenditures estimated at $33.7 billion in the United States.5 Furthermore, HF has been estimated to affect 10 per 1000 individuals after 65 years of age and 1 in 5 will develop HF after 40 years of age.6,7

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Readmission Rates for Heart Failure Patients

Readmission rates of HF patients are an area of great concern because HF is the leading cause of hospital admissions and readmissions in patients older than 65 years.8 More than 2.5 million Medicare beneficiaries were hospitalized for HF from 2001 to 2005, and 1 in 10 died within 30 days of hospitalization.9 The Centers for Medicare and Medicaid Services (CMS) began tracking 30-day readmission rates for HF in 2009 as part of the Hospital Readmission Reduction Program of the Affordable Care Act.10,11 As reported by the CMS (2009), the national average for HF readmissions is 24.5%. Based on these statistics, CMS has a goal to reduce hospital readmissions for HF by 20% in the year 2013.11 Currently, one-fifth of Medicare beneficiaries are readmitted within 30 days and 90% of those readmissions are unplanned or preventable, costing $17 billion.12

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Quality of Life

Individuals with HF experience a multitude of symptoms such as shortness of breath, fatigue, and edema that affect their quality of life (QOL). It has been shown that patients with chronic HF may still have major impairment despite optimal medical management.13 Frequently experienced symptoms by HF patients such as shortness of breath and extreme fatigue significantly restrict an individual’s ability to perform self-care and daily activities, which greatly affects their QOL.13–15

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National Cost and Burden of Heart Failure Care

Heart failure is one of the most costly diagnoses in the United States. The National Heart Lung Blood Institute (2010), reported $167.4 billion in direct costs of cardiovascular disease and $119.2 billion in indirect costs of mortality. Because HF is the most common diagnosis of hospitalized patients 65 years or older16 and it is one of the most costly diagnoses for Medicare, the Hospital Readmission Reduction Program plans to use the readmission data to reduce Medicare base reimbursements to underperforming hospitals by 1% in 2013, 2% in 2014, and 3% in 2015. This will affect inpatient services provided for all diagnosis-related group readmissions within 30 days of an HF admission.11

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What Is Transition of Care?

Previous literature has clearly shown that patients lack support from healthcare teams especially when transitioning from hospital to home.17 Transitions in care refer to patients transferring from a hospital to home. The transition points are vulnerable areas that contribute to high healthcare spending and lapses in quality and safety and are associated with increased rates of hospitalization.17 According to the American Geriatrics Society,18(p30) transitional care refers to the “actions designed to ensure coordination and continuity of healthcare as patients transfer between different locations.” The Patient Protection and Affordable Care Act also acknowledges transitions as a barrier to quality care and has initiated the Community-Based Care Transitions Program. The Community-Based Transitions Program goals are to reduce hospital readmissions, test sustainable funding streams for care transition services, maintain or improve quality care, and document savings to the Medicare program.19 Ideally, transitional care should begin during admission and continue at home and contain an element of communication between providers to ensure continuity. Most transitional care programs go beyond education alone to include the nurses’ role in coordinating multidisciplinary referrals based on the patient’s needs, communication among the inpatient team members as well as home care personnel, and developing/implementing tailored care plans that include patient and family education, medication management/titration, and increasing the patient’s activity levels/functional capacity. The purpose of this integrative review was to critically examine the effects of nurse-led transitional care interventions on hospital readmissions, QOL, and cost-effectiveness of these types of programs for HF patients and the healthcare system.

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This integrative literature review examines and summarizes previous research by drawing conclusions from separate studies that are believed to address related topics.20 The updated integrative review methodology of Whittemore and Knafl21 was used to conduct this integrative research review, which includes 5 review stages: problem identification, literature search, data evaluation, data analysis, and presentation (eg, manuscript).

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Problem Identification Stage

The problem addressed in this review was formulated by specifying the variable of interest and the appropriate sampling frame.21 The criteria used for including an article in this review were English-only, peer-reviewed, qualitative and quantitative research focusing on discharge planning and follow-up of HF patients 18 years or older.

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Literature Search Stage

A computerized search of the literature was conducted using PubMed, Cumulative Index to Nursing and Health Literature (CINAHL), Ovid Medline, Cochrane, Proquest, Web of Science, PychInfo, Embase, and Joanna Briggs Institute databases. Multiple text combinations used in the search included the following key words: HF, transitional care, transition of care, discharge, hospital to home, readmissions, and continuity of care. The literature search yielded 850 articles (see Figure). Sources reviewed were limited to peer-reviewed articles, with no date range selected to assess the full extent of literature.

FIGURE. Process of i...
FIGURE. Process of i...
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Data Evaluation Stage

Duplicate articles were discarded initially, then titles and abstracts were reviewed for content. Studies that were not in the English language and did not specifically have an intervention both predischarge and postdischarge with HF patients were excluded. The methodological quality of each study was evaluated using the integrative literature review instrument of Smith and Stullenbarger.22 It was determined that articles scoring less than an average of 20 points of a possible 48 points were excluded from the review. Three independent reviewers rated the remaining 23 articles, and 3 additional articles were discarded for low quality ratings.

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Data Analysis, Presentation, Display

The next step in data analysis involved data display, which consisted of converting the data from extracted sources into a display around variables or subgroups.21 We standardized and described the intervention dose as the number of visits over a 1-month period. An intensity rating scale (IRS) was designed to identify the intensity of each intervention (Table 1). High intensity was defined as outpatient contact greater than or equal to weekly visits; moderate intensity was defined as once a month or more up to weekly visits; and low intensity was defined as less than monthly visits. The sample, study type, measures used, intervention, and results are displayed in Table 2. The data displays of Table 3 allowed for data comparison of the studies’ primary outcomes. The final phase in data analysis was drawing and verifying conclusions,21 which is presented in the “Discussion” section.

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Table 2
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All studies included a transitional care intervention and a control group receiving usual care with sample sizes ranging from 70 to 1023 participants. The duration of the transitional care interventions ranged from 10 days to 18 months.

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Types and Length of Interventions Studied

Fifty-eight percent of the studies were rated as high-intensity interventions23,26,29–34,37–39 by the IRS, 21% were moderate intensity,27,28,35,36 21% were low intensity,24,40–42 and 1 study was not rated by the IRS owing to the lack of information regarding the number of encounters by the authors.25 Three34,37,43 of the high-intensity interventions included more than 1 visit during hospitalization as part of the transitional program, whereas 7 studies26,29–33,38,39 did not specify the number of inpatient visits. In 1 of the 20 studies reviewed, the duration of the intervention was not clearly identified.25,42 The IRS did not take into account the duration of the intervention. For example, 1 intervention consisted of 1 contact per month, which was classified as moderate intensity per the IRS even though it was only a 10-day intervention, which was a short intervention in comparison with the other studies.28 Fifteen of the 20 studies (75%) reviewed were composed of a multidisciplinary intervention (collaboration between nurses, dietician, physical therapist, physician, occupational therapy, social worker) while the patient was inpatient or outpatient or both.24–26,29–38,40,41 The types of transitional care interventions varied between education only25,35–37 or education with counseling,24,26,29–34,38,40,41 medication titrations,24,26,30,32–35,41 progressing activity levels,41 visits by the dietician,29,31–33,36,37 physical therapist, and/or occupational therapist.31,38

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Of the 20 studies included in this review 19 measured readmission rates as their primary endpoint. The timing of measured outcomes was 30 days,32,38,39 90 days,31,33,36,37 18 weeks,42 6 months,23,30,35,40,41 9 months,28 1 year,24–26,34 and 18 months.29 Ten of the 19 studies showed significant improvements in the intervention versus control group.23–25,33,34,37–41 Studies that yielded significant results primarily consisted of interventions that had intensive, tailored multidisciplinary nurse-led inpatient education and home care follow-up within 72 hours after discharge. The inpatient interventions, on average, were composed of education and counseling of both patient and family by a multidisciplinary team as well as securing follow-up appointments with the primary care physician or cardiologist before the patient’s discharge. The postdischarge interventions consisted of telephone contact, home visits, or a combination of both. The frequency of the home visits intervention ranged between 1 and 20 visits over the designated study period. Five studies with a comprehensive transitional care intervention had nonsignificant differences in the readmission rates among groups but reported that individuals randomized to the usual care groups received a high level of standard care, which possibly narrowed the differences between groups.26,28,29,32,35 Other authors reported the need for increased training of the interventionist in providing HF education and counseling as well as more care coordination and follow-up appointments with the providers.30,31 Study designs were classified as randomized control trials,24,25,28,33,34,37,40,41 prospective,39 quasi-experimental,23 or retrospective observational.38

Three of the 19 studies had a primary endpoint of 30-day hospital readmissions. Of these 3 studies, 2 reported a significantly lower readmission rate for the control group (43%, P < .01, Russell et al38; and 48%, odds ratio, 12.6; 95% confidence interval [CI], 7.4–17.8, Stauffer et al39). The study with nonsignificant findings had no deaths or readmissions for participants in either the intervention or the control group.32 Two of the 4 studies that measured readmissions at 90 days reported significant findings.33,37 Of the 4 studies, 1 focused on the patient’s being clinically stable with tight medicinal control before discharge from the hospital and during clinical follow-up. This intervention resulted in readmission rates of 25.5% for the control group versus 3.9% in the intervention group (P < .01).33 The second study had intensive education and multidisciplinary follow-up before discharge and between 6 and 20 home care visits based on the patient’s need over a 6-week period (P = .01; 95% CI, 2.8–17.4).37 These studies were rated as high intensity on the IRS. One study that had nonsignificant findings was rated as high intensity,31 and the other, as moderate intensity.36 Both studies provided education before discharge; however, the difference was the type of intervention used, telephone31 versus home visit.36 The high-intensity intervention used telephone follow-up, whereas the moderate-intensity intervention used home visits.

Five studies measured unplanned readmissions at 6 months; however, only 3 showed significant differences between the intervention and control groups (P = .01; P = .03; P = .05, respectively).23,40,41 One of the 3 studies with significant results were rated as high intensity23 and 2 were rated as low intensity40,41 on the IRS owing to the difference in the number of home visits and contacts made to the participants. The first of the 2 studies with nonsignificant findings used a combination of monthly nurse home care visits and as-needed telephone contact (rated as high intensity on the IRS)30 and the second study was rated as a moderate intensity intervention, which involved telephone contact plus clinic visits at 3 different time intervals (15 days and 1 and 6 months).35

Four studies24–26,34 measured readmissions at 1 year, of which 3 studies24,25,34 showed significant results. All 4 studies were randomized controlled trials. Blue et al25 found that the risk of hospital readmissions was reduced by 62% in the intervention group. Atienza and colleagues24 showed a significant reduction in readmissions by 16% (95% CI, 4%–28%; P = .004) in the intervention group as compared with the control, which was similar to Naylor and colleagues,34 who found a lower readmission rate and deaths at 1 year (intervention, 47%, vs control, 61.2%; P = .01). The study that did not show significant differences in readmission rates between groups (32% vs 37%) used only telephone contacts with 1 provider visit; however, it was rated as high intensity on the IRS.26

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Quality of Life

It has been clearly shown that if patients are not performing self-care, the chronic symptoms of HF can greatly affect the QOL of individuals living with this disease.44 However, self-care can be achieved if proper programs are in place that assist the patient with learning about their condition before and after hospital discharge.44 For example, 6 of the 20 studies reviewed measured the effects of a transitional care intervention on the participant’s QOL.24,27,34,35,37,41 Five of the 6 studies showed improvement in QOL despite the wide differences in the intensity of the interventions performed.24,27,34,37,41 Two of the 6 studies were rated a high-intensity interventions,34,37 2 were rated as moderate intensity,27,35 and 2 were rated as low intensity24,41 by our IRS (see Table 1). Of the high-intensity interventions, participants in the intervention group were more likely to report stable or improved symptoms in comparison with the control group at 12 weeks (P < .05, Naylor et al34; P = .001, Rich et al37). Likewise, a study using a moderate-intensity intervention found that the transitional care intervention group had clinically significant improvements in their reported health-related QOL at 6 (P = .002) and 12 (P < .001) weeks.27 The study of Nucifora and colleagues35 was rated as a moderate-intensity intervention; however, they found nonsignificant differences among the groups in QOL at 6 months. Five of the 6 studies that measured QOL used the Minnesota Living With Heart Failure Questionnaire,24,27,34,35,41 whereas 1 study used the Chronic Heart Failure Questionnaire.37

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Cost of Transitional Care Interventions

Nine of the 20 studies measured cost of conducting a transitional intervention program.23,24,30,31,34,37,39–41 Six of the 9 studies showed significant cost savings in the intervention groups.23,24,30,34,37,39 Total 60-day direct costs of HF admissions at the intervention site were compared with costs throughout the hospital system and against current costs of standard care with readmissions.39 Two studies found a cost improvement by the intervention versus the control group (P = .002).24,34 One study had a total outpatient cost of $1541 per participant. The authors used this information to estimate costs for inpatient readmissions and found a savings of $91 000 for the intervention group (P = .001).23 Similarly, the mean total costs of a 3-month intervention with a 52-week follow-up for HF readmissions yielded a decrease in readmissions by 6% and a cost savings of $4845 per patient.34 One transitional care program produced a net reduction in the use of hospital resources by 51%, which resulted in an overall cost reduction of $2338 per participant in the intervention group.24 Furthermore, a cost analysis at 1 year showed a 19% reduction in readmissions.24 When measuring the overall cost of care for high-risk HF patients older than 70 years, on average, the control group expenses were $153 higher per participant each month compared with the control group.37 Others found a significant cost savings for the intervention group ($5229 vs $20 916; P = .048) owing to less emergency room and inpatient hospital visits. However, there were nonsignificant cost savings for outpatient visits at 6 months ($1457 vs $922; P = .118).30 Three studies showed a decrease in hospital readmissions in the intervention group; however, this difference was not statistically different from the control group.31,40,41

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The purpose of this review was to synthesize the literature relating to transitional care programs for HF patients and the effects of these programs on hospital readmission rates, QOL, and cost-effectiveness. Comparisons of transitional care programs identified a gap in the literature pertaining to transitional care in HF patients as well as the great variability in the programs that have been studied. Only 20 studies were found that examined predischarge and postdischarge interventions for HF patients, demonstrating a gap in the literature and the need for continued research. From this review, it is clear that transitional programs have the potential to reduce readmission rates, improve QOL, and reduce cost. Interventions that had intensive tailored, multidisciplinary nurse-led inpatient education and counseling as well as home care follow-up within 72 hours postdischarge and interventions comprising of home visits alone or in combination with telephone follow-up were the most successful in yielding significant reductions in readmissions, QOL, and cost.

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Intervention Dose

The structure of the interventions reviewed in each program varied greatly. The 1 consistent variable in all 20 studies was that patient contact occurred during hospitalization and after discharge. The inpatient interventions was composed of 1 or more of the following components: HF education by a nurse, dietary education, medication education/titration, and physical/occupational therapy visits. In addition, inpatient interventions were composed of care coordination among the healthcare team members to ensure continuity of care and the consultation of appropriate ancillary services. The outpatient interventions included telephone interventions, patient home or office visits, or a combination of both physical and telephone contact. Eight studies did not show a significant improvement in their readmission rates.26,29–32,35,36,42 The lack of significance between the 2 groups could be because of the high level of standard care that the usual care group received.

Duration of the interventions and length of time to measure outcomes varied among the 20 studies. Because of the inconsistent duration of interventions and outcomes measured, it is difficult to conclude which intervention duration would be most effective for transitional care programs; however, the most successful interventions were composed of frequent home visits by a nurse and those that were tailored to the patient’s specific needs and or deficits in knowledge. There were significant decreases in reported hospital readmissions at 30 days,38,39 90 days,33,37 6 months,23,40,41 and 1 year.24,25,34 Unfortunately, there was not sufficient evidence available to evaluate if the benefits of the transitional care programs decreased over time. Only 3 of the 19 studies in the current review measured rehospitalizations at multiple time points.28,32–34 However, according to the data gathered in these 3 studies, there were no significant differences among groups for rehospitalizations at any measured time point, with the exception of the first time point immediately after the intervention. The remaining 16 studies measured readmissions at baseline and at the study endpoint only. Future research should measure readmissions at greater intervals throughout the study to tease out the beneficial effects for HF patients enrolled in transitional care programs over time. There was also variation in educational preparation of the healthcare providers. Two of the studies used advanced practice nurses to deliver care,34,39 whereas others described specially trained nurses and even nurses without any specific HF training. Naylor and colleagues34 suggest that the flexible protocols guided advanced practice nurses and allowed them to address other comorbid conditions that contribute to poor outcomes and readmission of elderly HF patients. Comparing the educational background of healthcare providers and the effects on readmission rates, QOL, and healthcare costs did not reveal that any one was more effective than another.

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Quality of Life

Five of the 6 studies measuring QOL showed improvement after baseline. The earliest improvement was measured at 6 weeks.27 Subsequent durations of improvement in QOL were seen at 12 weeks, 6 months, and 1 year,24,27,34,37,41 with 12 weeks showing the strongest impact on improving QOL during all measurement intervals. For example, Naylor and colleagues34 measured QOL at baseline and at 2, 6, 12, and 26 weeks, with the strongest impact on QOL at 12 weeks. Harrison and colleagues27 measured QOL at baseline and at 2, 6, and 12 weeks, with the strongest impact at 12 weeks. Stewart and colleagues41 found a significant improvement in QOL at 3 months, but not at 6 months. Nucifora and colleagues35 found no significant changes in QOL from baseline to 6 months follow-up. Within this small sample of studies, it is uncertain why the improvements occurred more often at 3 months; however, these data suggest that it may be beneficial to increase the length and intensity of the postdischarge interventions to test for significant effects. Future studies should continue to evaluate QOL at regular study intervals to determine the types of interventions that are sustainable over time.

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Three of the 9 studies included in this review showed a reduction in cost in the intervention groups when compared with usual care. This may indicate that when readmissions are reduced in the presence of transitional care programs, the overall cost to the healthcare system at large is decreased. This reduction in costs may occur with participants in the transitional care programs because these programs help patients stay well in their home longer, thereby reducing the need for frequent readmissions. Two of the 6 studies did not show a significant decrease in healthcare cost but did have a significant decrease in readmissions.40,41 The 2 studies that failed to show a cost savings had these costs offset by the increased cost of the home visits resulting from the intensity of the postdischarge intervention.40,41

The recent CMS quality improvement policy regarding 30-day readmissions was not considered in the studies reviewed. Therefore, they did not factor in lost payments due to 30-day readmissions from the Medicare and Medicaid covered patients. Considering this in future research may result in a more significant impact on lowering costs especially because reimbursements of all-cause readmissions within 30-days of a HF discharge could decrease based on CMS regulations. These reimbursement practices will also extend into other medical diagnosis. Each study that demonstrated a reduction in costs also reduced readmission rates. These findings reinforce the impact that readmissions have on costs, specifically that lower readmission rates in HF patients lowers costs. Only 2 of the interventions measured 30-day readmission rates. Because of the upcoming reimbursement policies to be enacted by CMS, 30-day HF readmissions as well as 30-day all-cause readmissions should be studied more closely.

In summary, transitional care programs have the potential to reduce readmissions, reduce cost of care for HF patients, and improve QOL. The findings of this review revealed that tailored inpatient education and counseling along with tailored outpatient interventions consisting of home visits coupled with telephone contacts can significantly reduce readmissions, increase QOL, and decrease cost in high-risk HF patients. However, more research must be completed to evaluate the sustainability of a nurse-led transitional care intervention for high-risk HF patients.

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What’s New and Important

* Nurse-led transitional care programs have the ability to positively influence readmission rates, quality of life, and healthcare costs.

* Home visits combined with telephone contacts may be the most effective way to transition heart failure patients from hospital to home.

* More research is needed in this area to study sustainability over time.

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Nineteen of the 20 studies measured readmission rates. However, we were unable to account for the variability of comorbidities within each sample of patients with HF. The variability in acuity and comorbidities may have affected and/or attributed to increased readmission rates regardless of the intervention performed. Of the 20 studies reviewed, only 6 studies measured QOL, which limits the generalizability of our findings for the variable QOL. Second, the methods of measurement used to analyze cost varied throughout studies, and a majority of the studies did not use statistical analysis, making it difficult to formulate any conclusions. In addition, the studies that did perform cost analysis did not examine the effects of the Patient Protection and Affordable Care Act reimbursement policy that will come into effect in the year of 2013. Furthermore, interventions varied in the frequency of contact, intervention duration, method of contact, education of providers, and timing of when outcomes were measured. One study identified the length of telephone conversations made between providers and participants but no other study described the average length of each patient contact. Lastly, it was difficult to fully evaluate 1 study that did not detail the components of their intervention.

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Research Implications

To move the science forward in refining transitional care interventions for patients with HF, future research study designs and subsequent research reports need to specifically address the following: frequency, interval, duration, and content of the intervention; frequency and duration of inpatient contact; timing of initial outpatient contact post discharge; type of patient contact provided; and level of provider used to implement the intervention. Once these factors are described and have demonstrated their effectiveness over time, researchers should design and implement transitional care programs for HF patients in a “real world” practice setting to evaluate their effectiveness.

An additional aspect of transitional care is the healthcare team communication between settings. Details into how transitional care information is transferred during the intervention are vital to understanding how healthcare teams can improve continuity. Other critical information is the healthcare costs of transitional care programs as well as financial consequences to the healthcare system. To demonstrate the full financial impact that transitional care programs can have once CMS reimbursement policies change in 2013, all-cause readmission rates should be measured at 30 days and comparative cost analysis performed.

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Practice Implications

Nurses and other practitioners have the opportunity to improve the transitional care process for HF patients within their organizations. The Affordable Care Act and the Administration on Aging45 provide easy-to-use toolkits that help guide healthcare teams with developing the infrastructure necessary for improving the effectiveness of transitioning individuals with chronic illnesses from acute care facilities (hospital) to the community or nursing home settings. This toolkit supports healthcare teams with reducing the occurrence of frequent hospital readmissions and provides funding resources to build successful transitional care programs. Specifically, some of the topics covered are developing policies and procedures, expected costs and billings, how to appropriately staff the program to accomplish your goals, how to measure for quality improvement, building formal partnerships, and how to build your reputation within the community. Furthermore, information is available on the types of funding mechanisms for transitional care programs including program announcements and grant application instructions.

Healthcare teams can use this integrative review to understand the gaps in the literature and the types of interventions that produce significant changes that will reduce hospital readmissions, decrease healthcare cost, and increase QOL in HF patients. This information, coupled with the Administration on Aging’s toolkit and grant opportunities, provides crucial information to build a successful transition program designed to achieve positive outcomes.

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heart failure; nurse-led interventions; readmissions; self-care; transitional care

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