It is not uncommon for patients with heart failure (HF) to be admitted to the hospital four to six times per year (Chen et al., 2011). Approximately 27% of patients with this health condition are readmitted to the hospital within 30 days of the initial hospital discharge (Dharmarajan et al., 2013; Feltner et al., 2014; Jencks et al., 2009), with estimates that at least 75% of these hospital readmissions are avoidable (MedPAC, 2007). The most frequent reasons for readmission of HF patients include recurrent HF (40%), renal disorders (8%), and pneumonia (5%) (Dharmarajan et al.). The vast majority of these hospital readmissions (70%) occur between 7 and 30 days after the initial hospital discharge (Dharmarajan et al.). As hospitals with higher than expected readmission rates for HF patients are financially penalized by a reduction in their total renumeration from the Centers for Medicare and Medicaid Services reimbursement (1% to 3% reduction depending on year of program), it is essential to take actions to decrease or avoid readmissions within 30 days of discharge.
In an effort to prevent hospital readmissions for HF patients, intervention studies have evaluated methods to improve patient transition from hospital to home. The goal is to maximize patient adherence to medication regimes, prevent fluid overload, and assist patients to self-monitor for signs/symptoms of medication and/or fluid overload problems. Two general types of transition programs have been evaluated: patient attendance at multidisciplinary outpatient clinics at regional centers and home healthcare (HHC) visits (Fergenbaum et al., 2015; Hansen et al., 2011). Although a number of studies have shown the use of special, multidisciplinary outpatient clinics significantly decreased readmissions (McAlister et al., 2004), this type of intervention is not always a feasible approach due to lack of specialized personnel who could manage a regional, specialty clinic. A recent study by Stewart et al. (2012) determined that similar outcomes were achieved when the transition care was delivered in a special, multidisciplinary clinic or a single HHC visit by a registered nurse (RN) within 7 to 14 days after the initial hospital discharge.
A more feasible approach to transitioning HF patients from hospital to home is HHC visits, during which an RN assesses patient knowledge of their disease management, providing education as needed. In addition, the RN monitors the patient's physical status for signs and symptoms of fluid overload and/or medication problems, common reasons for readmission after discharge. Based on communication with the primary care physician (PCP), changes to the patient's medical regime are made (i.e., changes to diuretic or hypertension medications) and/or arrangements are made for the patient to visit their PCP.
Six randomized controlled trials have compared HHC visits with usual care by their PCPs in HF patients after hospital discharge (Aguado et al., 2010; Inglis et al., 2006; Jaarsma et al., 1999; Kwok et al., 2008; Morcillo et al., 2005; Stewart et al., 1998). Most of the studies involved a single HHC visit within a week (Aguado et al.; Inglis et al.; Jaarsma et al.; Stewart et al., 1998) or within a month of hospital discharge (Morcillo et al.). Only one study had more than one HHC visit, with one visit a week for 4 weeks and then one visit per month for 6 months (Kwok et al.). All but one of the six studies found hospitalizations within the study time periods (3 to 6 months) to be significantly lower for the HHC visit group compared with usual care group, with most studies reporting a 10% to 25% reduction in readmission rates. Only Kwok et al. found no difference in hospital readmission rates between the intervention and control groups.
Following a systematic review of studies of interventions to decrease hospital readmissions within the initial 30 days postdischarge, Hansen et al. (2011) concluded additional studies are needed on postdischarge strategies that support the patient between discharge and follow-up visits to their PCP. These authors posit that the postdischarge period is a particularly vulnerable time, when patient experiences a “voltage-drop” in the availability of both care and knowledge.
HF patients discharged from North Kansas City Hospital, the study site, received 3 HHC visits by an RN during the first week after hospital discharge, followed by 2 visits per week for the ensuing 3 weeks. These HHC visits have several goals: patient education to promote self-care (medication adherence; fluid balance monitoring; symptom recognition; dietary restrictions) and HF pathophysiology, RN monitoring of symptoms, and early recognition of fluid overload and medication problems (nonadherence; intolerance; improper administration). As hospital lengths of stay are shorter today, the initial week HF patients are home following hospital discharge is still of time of recovery from illness and sleep deprivation experienced during hospitalization. Information about self-care activities during that first week after discharge may be difficult for the patient to absorb, given that they have not yet fully recovered from their HF hospitalization.
Decreasing the number of home visits that normally occur in the week after discharge to a time when the patient can focus and better understand information (e.g., week 3 after discharge) might improve retention of information. The primary focus of visits week 1 should be the close monitoring for symptoms of complications and/or worsening HF, and limiting patient education to essential self-care activities only. Other education about self-care promotion and disease pathophysiology normally done during the 1st week after discharge could be addressed with an additional HHC visit during the 3rd week after discharge. The purpose of this study was to determine if the timing of HHC visits after hospital discharge affects 30-day hospital readmissions for HF patients.
Materials and Methods
This study was conducted in a 451-bed community-based hospital in the Midwest region of the United States. The setting was an outpatient, HHC department staffed by 30 RNs. Study approval was obtained from the institution's investigational review committee prior to data collection. Data were collected over an 8-month period (10/16 to 05/17).
Study Design. Using a randomized control trial format, this study was designed to evaluate the timing of two different schedules for HHC visits for HF patients after hospital discharge. The primary dependent variable for this study was the number of hospital readmissions within 30 days of discharge for an HF-related reason. Random assignment to groups was done using a computer randomization program (Figure 1).
Sample Selection. Subjects for this study were patients admitted to HHC services within 4 days of discharge from the hospital. Inclusion criteria for participants included: mentally competent; diagnosis of HF; physically able to perform daily weights; and not currently receiving renal dialysis. Sample size based on power analysis with an effect size of 0.71, power of 0.8, and alpha of 0.05 determined a minimum sample size of 64 patients was required (Cohen, 1977; Faul & Erdfleder, 2018). Effect size was calculated and based on a 20% decrease in the usual number of patients requiring readmissions within 30 days of hospital discharge at the hospital (18.6%).
Intervention. Two different schedules for HHC visits after hospital discharge were studied (Figure 1). The type of assessment, monitoring, and education provided by the RN during each visit for the 4-week period after discharge followed a standardized protocol for both study groups (Table 1). The visits were recorded in an HHC visit log (Supplemental Digital Content 1, available at http://links.lww.com/HHN/A87).
Outcome Variables. The primary outcome variable for this study was the hospital readmission rate, which was determined by review of daily hospital admission logs and direct questioning of the patient and/or family about readmission to the hospital for an HF-related admission. Secondary outcome variables included the number of emergency department (ED) visits and number of contacts by the HHC nurse to the PCP. The patient and/or family members were queried during each visit about whether care was sought in the ED since the last HHC visit. During each visit, the RN recorded contacts with the PCP and the reason for the communication. In addition, RNs identified evidence of worsening HF and problems with adherence to weight monitoring, following medication regimes; and/or sodium and fluid restrictions.
Study Procedure. RNs providing visits to study participants were trained in the study procedures prior to patient enrollment. Consenting patients were randomly assigned by a computer-generated number sequencer on the day of the first visit to either the usual or intervention group visit schedule. Nine HHC visits were then provided over a 4-week period by RNs according to the assigned group schedule.
Data Analysis. Data were summarized using descriptive statistics. Independent sample t-tests were calculated to determine if the number of readmissions within 30 days postdischarge was different between the study groups. Chi square analysis was used to determine if the number and type of adherence problems were similar for the two groups over the 4-week HHC visit schedule. The level of significance for all tests was preset at p < 0.05.
A total of 67 HHC patients were recruited over the data collection period (usual HHC, n = 32; intervention HHC, n = 35). Participant age ranged from 44 to 95 years, with a mean of 79.0 ± 10.5 years (Table 2). Besides HF, each participant had a history of at least one other chronic disease; many had two or more chronic conditions. Sixty of these participants (90%) were diagnosed with HF prior to their most recent hospitalization. No difference was found between the two HHC visit schedule groups for any of the demographic or patient characteristic data (p > 0.05).
Eleven percent (n = 7) of the participants were readmitted to the hospital during the 4 weeks of the study (n = 3 usual HHC visit group; n = 4 intervention HHC visit group) (Supplemental Digital Content 2, available at http://links.lww.com/HHN/A88). Three participants (5%) had an ED visit during the study period (n = 1 usual HHC group; n = 2 intervention HHC group). No differences were found between the two groups on either of these outcome variables (p > 0.05).
During the 4-week study period, RNs contacted the patient's PCP 67 times, with a similar number of calls occurring in both treatment groups (p > 0.05). The highest number of calls/week occurred in the 1st or 2nd week of the study period.
Evidence of HF was present in about a third of the patients during the 1st week of the study (n = 11 usual care group; n = 11 intervention group) (Supplemental Digital Content 2, available at http://links.lww.com/HHN/A88). A majority of participants had not been monitoring their daily weights during the 1st week of the study (n = 10 usual care group; n = 10 intervention group) or following sodium/fluid restrictions (n = 15 usual care group; n = 11 intervention group). Adherence with weight monitoring and sodium/fluid restrictions improved over the next weeks of the study. Fewer participants were not adherent with their medication orders in the first week of the study (n = 7 control group; n = 5 intervention group), with all having a poor understanding of their medication orders. No statistical differences were identified between the usual care and intervention groups for any of these variables (p > 0.05).
This study compared differing schedules of HHC visits and determined the timing of the visits did not impact any of the variables studied. Thus, the evidence does not support the perception of many HHC RNs who posit that “front loading” HHC visits (having larger numbers of HHC visit during the 1st week after discharge, with fewer visits later in the 30-day period) decrease hospital readmission rates. The progression of HF occurs in about 20% of the patients through the 4th week after discharge. Compliance with sodium and fluid restrictions was most challenging to the participants of this study, despite the fact that they verbalized an understanding of the restrictions. This underscores the need for HHC visits throughout the 30-day monitoring period. This schedule provides more time to assist patients in adjusting to the changes in lifestyle that need to occur to better manage this chronic disease. The noncompliance of the study population with respect to their plan of care is perhaps the biggest nursing challenge identified by this study. The development and implementation of a daily checklist may provide guidance for patients as they monitor their health condition.
Participants in this study had one, if not more, comorbid health conditions. This variable may have influenced the results, as the readmission may have been a result of the comorbidity, or the comorbidity along with HF. Replication of the study using specific inclusion criteria would allow evaluation of the intervention among those with uncomplicated HF, or with HF complicated by a specific comorbidity. Thus, the conclusion that the intervention failed to alter readmission rates should be viewed with caution. The posthospital HHC visits were effective, as demonstrated by an 11% readmission rate, so determining the timing and frequency of these visits should guide the next study.
Conclusion and Clinical Implications
The management of HF in the home setting is challenging. There are many variables that impact the ability of the patient to manage their health condition. As a chronic, progressive disease, decline occurs even under the best of circumstances. The best practice, for HHC RNs, should include knowledge and understanding of comorbid conditions, the skills to teach sodium and fluid restrictions, and anticipated disease progression. Certainly, HHC visits are recommended, and should be guided by patient needs, support services available, and treatment choices. Replication of this study is recommended, specifically with a focus on comorbidities present, the knowledge level of the patient/family about the disease process, and lifestyle choices.
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