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Hearing the Veteran's Voice in Congestive Heart Failure Readmissions

Stevenson, Carl W. RN, BSN; Pori, Daria RD, DSO; Payne, Kattie PhD, MSN, RN; Black, Mary RN, MSN; Taylor, Victoria E. BSN, MSA

doi: 10.1097/NCM.0000000000000080
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Purpose/Objective: Our purpose was to examine congestive heart failure (CHF) readmissions from the veterans' perspective. The use of health care provider interventions, such as standardized education materials, home telehealth, and a CHF clinic, was able to reduce readmissions rates from 35% to 23%. Our objective was to use input from the veterans to fine-tune our efforts and achieve readmission rates for patients with CHF below the national average of 21%. We wanted to identify factors that result in CHF readmissions, including disease education, self-care management, and barriers to self-care. This study was directed toward answering two questions:

  1. What is the veteran's explanation for readmission?
  2. According to the veteran, what are the barriers to following their treatment regimen?

Primary Practice Setting: It was a rural 84-bed Veterans Health Administration hospital in the Western United States.

Findings: Before this study, our efforts to reduce CHF readmissions were one-sided, all from the health care professionals' viewpoint. We wanted to hear what the veteran had to say; so, we interviewed 25 veterans. Four veterans were excluded due to issues with their consents. Ninety percent (n = 19/21) responded that they knew their CHF was worse by a change in their breathing (shortness of breath). They identified 48 signs/symptoms that indicated worsening CHF. Weight gain was noted as an indication of worsening CHF symptoms (n = 6/48) in 12.5% of the responses. Twenty-five percent (n = 12/48) of the veterans stated they recognized the early symptoms of worsening CHF. Thirty-eight percent (n = 8/21) of the veterans stated they had early symptoms of worsening CHF, but only two of them contacted their doctor. It is interesting to note that only 29% (n = 6/21) of the veterans recognized weight gain as a sign of worsening CHF and all of these veterans listed other symptoms (such as shortness of breath) along with weight gain. Weighing on a daily basis was practiced by only 30% of the group (n = 7/21); all but two of the veterans had no problems with weighing themselves. More than 71% of the veterans responded that they had no problems following their diet or taking their medications. More than half of the veterans did not need help with meals, transportation, or daily grooming/dressing/toileting.

Conclusions: We were concerned about the evident delays in seeking medical care for worsening CHF. All veterans who did need help with the activities of daily living, medications, or diet had their needs met through their support systems. They did not perceive any barriers to seeking care. However, there remain many unanswered questions. Does the patient understand their discharge education and know how to use this information from daily weights or recognition of early symptoms, to indicate their need for urgent and emergency medical interventions? Or is it a problem that the education is not sufficient? Is it a question of the burden of care from multiple comorbid conditions or of taking too many medications? Do social issues drive readmissions? These questions are further explored in a second study, which is in the data analysis stage.

Implications for Case Management Practice: There are three key findings from our study.

  1. Veterans think in terms of symptoms that increase the impact of CHF on their life.
  2. The relationship between daily weight and controlling CHF is not clear to veterans.
  3. Hospital discharge instructions should clearly associate symptoms that are associated with worsening CHF.

Carl W. Stevenson, RN, BSN, has 23 years of experience as an RN in cardiac care, medical/surgical nursing, and quality improvement for local and national VA committees. He has been conducting research with patients with CHF for the past 5 years. He has presented a podium presentation and three poster presentations on this topic.

Daria Pori, RD, DSO, is a registered dietitian with 23 years of experience helping people manage chronic diseases, including heart failure, with the appropriate medical nutrition therapy for their conditions.

Kattie Payne, PhD, MSN, RN, has 42 years of experience as an RN in bedside nursing, family nurse clinician, health care administration, nursing education, and writing consumer education materials. Her passion is caring for those with diabetes or heart disease. Her dissertation focused on hospitalized patients taking cardiovascular drugs.

Mary Black, RN, MSN, has 18 years of experience as an RN in medical surgical nursing, nurse educator, and nurse manager. She has worked with patients with CHF and helped them focus on disease management from admission diagnosis of CHF, inpatient care, CHF risks, symptoms, treatment, and lifestyle choices.

Victoria E. Taylor, BSN, MSA, has 34 years of experience as an RN in several areas, including cardiac care, military nursing and maternity care. However, she currently works in Home Tele health at the Boise, VA, where a large portion of her patient caseload has congestive heart Failure.

Address correspondence to Carl W. Stevenson, RN, BSN, Boise VA Medical Center, 500 West Fort Str, Boise, ID 83702 (carl.stevenson@va.gov).

The authors report no conflicts of interest.

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