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:
- What is the veteran's explanation for readmission?
- 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.
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.
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.
- Veterans think in terms of symptoms that increase the impact of CHF on their life.
- The relationship between daily weight and controlling CHF is not clear to veterans.
- Hospital discharge instructions should clearly associate symptoms that are associated with worsening CHF.