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Heart Failure: Self-care to Success: Development and evaluation of a program toolkit

Bryant, Rebecca DNP, FNP-BC

doi: 10.1097/01.NPR.0000520833.22030.d0
Online exclusive

Abstract: The Heart Failure: Self-care to Success toolkit was developed to assist NPs in empowering patients with heart failure (HF) to improve individual self-care behaviors. This article details the evolution of this toolkit for NPs, its effectiveness with patients with HF, and recommendations for future research and dissemination strategies.

Rebecca Bryant is an assistant professor at Ohio University, Athens, Ohio.

The author would like to thank Phyllis Gaspar at Toledo University and Tracy Brewer at Wright State University for their collegial and professional encouragement to publish this toolkit.

The author has disclosed the following financial relationships related to this article: Grants from the American Association of Nurse Practitioners and the Gerontological Advanced Practice Nurse Association.

Heart failure (HF) is one of the top primary medical conditions reported for inpatient hospital admissions among Medicare recipients age 65 and older.1 Patient perceptions following hospital discharge include a lack of self-care in their daily life, HF symptom recognition, and caregiver knowledge and support of HF status.2 Healthcare utilization is preventable with improved self-care skills.3,4

The Patient Protection and Affordable Care Act (ACA) legislated one of four value-based modifiers (Hospital Readmission Reduction Program) to report 30-day hospital readmission rates for HF in 2010, with payment adjustments starting in 2013.5 As a result, an emphasis was placed on HF education with the inpatient population to decrease 30-day readmission rates.6,7 This trend impacted all eligible professionals (including NPs) as a downward payment adjustment for those who do not satisfactorily report data using specific Physician Quality Reporting System measures in 2015.7,8

This article details the evolution of an evidence-based practice (EBP) tool to promote self-care behaviors in patients diagnosed with HF; the development of the Heart Failure: Self-care to Success (HF S2S) toolkit; the evaluation of this toolkit to improve self-care behaviors and decrease hospital utilization; and recommendations for future research and dissemination strategies in healthcare systems and community partnerships.

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Conceptual framework

Larrabee's A Model for Change to Evidence-Based Practice guided an EBP doctoral project, which included development of the toolkit during step four.9 This model was used due to its ease of description, applicability to HF self-care, and comprehensive six-step process.9 The model describes six steps toward an EBP change:

  • assessing for practice change needs
  • locating the best evidence
  • a critical appraisal of the evidence
  • designing the practice change
  • implementation and evaluation of this recommended change
  • integration of the change into practice.9
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Literature review

An exhaustive literature review was completed to identify available self-care of HF programs that could be implemented by NPs in a variety of practice settings.

Table Da

Table Da

Search strategy. The search strategy for this project was conducted using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and MEDLINE. A combination of keywords and subject headings in all databases included “self-care,” “heart failure,” “homebound elderly,” “NPs,” “hospital admissions,” “homebound persons,” and “patient admissions.” Additional studies were obtained by searching reference lists of relevant articles. National HF organizations and the National Guideline Clearinghouse were reviewed for applicable outpatient self-care of HF recommendations (see Databases searched and data abstractions).

Titles of articles containing one of the keywords (self-care or HF) were reviewed for inclusion. Selection criteria for further review of studies contained both outpatient self-care of HF interventions and hospital admissions as outcomes within their abstract. A hand search of references from the reviewed studies resulted in several secondary articles. The National Guideline Clearinghouse search resulted in one national HF guideline that included maintenance and management of HF paralleling the concepts in the Self-Care of Heart Failure Model.4,10 The American Heart Association (AHA) published a scientific consensus statement promoting HF self-care.11

Inclusion and exclusion criteria. Inclusion criteria focused on studies with outpatient self-care of HF interventions (HF education, self-recording of weight and symptoms, symptom recognition, and medication adherence), patients over age 65, and outcomes of hospitalization (length of stay, admission, and readmission rates). Due to increased hospital utilization and multiple comorbidities, patients need HF education outside the tertiary care service area.12 Research studies including outpatient self-care of HF interventions and hospital admissions as an outcome were the primary focus. All types of study designs were included.

Patients participating in a self-care of HF program need to be able to perform self-care activities. Studies including patients with HF as well as cognitive impairment, HF disease management-only interventions, in-hospital interventions, and telephone or other technology interventions were excluded. Four articles were kept for the foundational base of the project.10,13-15 Five studies relevant to the project's purpose were kept for critical appraisal.5,16-19 Two guidelines kept for the HF S2S intervention content development were appraised for quality.4,11

Critical appraisal. All five studies included self-care of HF interventions on an outpatient HF population and measured the impact of these interventions on hospital admission rates. Windham and colleagues also measured the change in self-management skills as an outcome.19 The self-care of HF interventions were delivered in multiple settings, including hospitals, outpatient clinics, and internal medicine and cardiology private practices.

Several studies (varying in sample size) included telephone contact as a component of the intervention. Three systematic reviews appraised between 11 and 34 randomized controlled trials (RCTs), and Windham and colleagues reviewed 32 articles in the literature review.5,16,18,19 Dewalt and colleagues had 123 participants in their RCT.17

The strength of this appraisal was the high level of research designs, which offered an increased confidence level for the interventions and outcomes. The relevant evidence included three systematic reviews of RCTs, one RCT, and a systematic literature search using self-care of HF interventions and their impact on hospitalization rates.5,16-19 There were several limitations of this appraisal.

There was no standardization among the self-care of HF interventions; a varied range of professionals delivered these interventions and only one study reported a conceptual framework, making it difficult to determine the independent effects of these interventions on outcomes.17 Dewalt and colleagues' study was the only RCT, and it was limited due to its small sample size.17

Two guidelines were kept for the development of HF S2S.4,11 The Heart Failure Society of America (HFSA) specifically makes recommendations for education using nonpharmacologic maintenance and management of HF.4 The AHA published a scientific statement on HF self-care, and both of these guidelines were evaluated using Appraisal of Guidelines for Research and Evaluation (AGREE II).11,20 AGREE II is an online platform tool that can be used by healthcare professionals to appraise the quality and rigor of clinical practice guidelines. This tool recommends at least two appraisers to increase the reliability of the assessment.

The guidelines' domain scores in scope and practice, stakeholder involvement, and rigor of development were similar. Both overall guideline assessment scores were rated high and applicable to the project purpose by two reviewers, with the AHA scientific statement having an increased focus on self-care.

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Table Effec

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Table Defi

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Synthesis of best evidence

Five research studies demonstrated a decrease in all-cause hospitalization rates (ACHR) and HF hospitalization rates (HFHR) related to self-care of HF (see Effect of HF self-care interventions). Three of the studies showed a statistically significant decrease in hospitalizations.16-18 Ditewig and colleagues and Windham and colleagues showed a reduction in hospitalization rates, but statistical significance was not reported.6,19

A decrease in hospitalization rates was reported with self-care of HF interventions. A synthesis of the self-care of HF interventions was reported in the five studies, and two guidelines included some aspect of symptom management, treatment management, and physical consequences (see Defined criteria of self-care interventions). Cognitive behavioral response, multidisciplinary interventions, home visits, and structured guidelines were implemented in over 70% of the studies as a part of the self-care of HF intervention.

Evaluation and synthesis of the best evidence must account for gaps in the literature. There were four issues identified as gaps in this synthesis:

  • Difficult-to-assess independent effects of self-care of HF components (weight monitoring, activity, medication management, and diet) on hospitalizations
  • No standardization of self-care of HF interventions
  • Minimal home-based self-care of HF education programs
  • Frameworks not used in higher-level evidence studies.

Minimal application of theoretical frameworks to guide research or conceptualize terms makes study comparison difficult. In addition, multiple self-care of HF intervention components lacked clear definitions or standardization, making comparison of results between studies difficult. Synthesis of the self-care of HF components following the appraisal guided the HF S2S program content and intervention design.

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Development of the HF S2S program

The Self-Care of Heart Failure Model guided the content development and implementation of the HF S2S toolkit over 12 months. In this EBP project, HF S2S was developed and implemented using the best available evidence as a support and guide. The HFSA nonpharmacologic HF guidelines and AHA expert opinion were incorporated into HF S2S program content.4,11 Four NPs with expertise in HF education/management provided feedback throughout the development and evaluation of this program.

The Self-Care of Heart Failure Model components of HF maintenance, HF management, and HF confidence are evident in the HF S2S program.10 This program includes an individual calendar and a toolkit guide for implementation by NPs (see HF S2S program toolkit). The HF S2S program calendar contains a self-record symptom area. A 12-month calendar encourages patients to record their weight, monitor symptoms, and reminds them to take daily medications (see HF S2S calendar page). The opposite side of the self-record system includes education on HF knowledge, maintenance (symptom monitoring), and management (treatment) information.11

Contact information is completed containing the phone number of the NP, emergency contact, and cardiologist. The last page of the calendar is a record of the patient's current medications. The patient is encouraged to share the calendar with caregivers and other healthcare providers. HF S2S is self-paced by patients along with one-on-one discussions with the NP during regularly scheduled office visits. One-on-one counseling is reported to be beneficial to patients.13

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Evaluation of the HF S2S program

The HF S2S was piloted by NPs in a house call and cardiology practice to measure effectiveness on patient outcomes and processes. Both of the research pilots used a single-group, pre- and postintervention design, and were externally funded. The purpose of the pilots was to compare HF hospital admission rates and self-care of HF behaviors before and after HF S2S. The hypothesis was that the use of HF S2S by direct care NPs would decrease HF hospital admission rates and improve self-care behaviors.

The house call practice pilot was funded by a foundation grant from the Gerontological Advanced Practice Nurses Association. The project was approved by the university's Institutional Review Board. The pilot recruitment began in January 2012 and lasted 6 months. Bryant, the principal investigator, reported that 6 months following HF S2S implementation, they had 18 participants in the urban Midwest, 0 HF hospital admissions, and a statistically significant increase in their self-care of HF behaviors (maintenance 5.7[16], p < 0.001; management 4.9[4], p = 0.008; confidence 6.9[17], p < 0.001) using the Self Care of Heart Failure Index (SCHFI, version 6.2).21,22 A post hoc power analysis was performed using Statistical Package for Social Sciences (SPSS) version 15 on the SCHFI scores. The power was 0.98 for maintenance, 0.95 for management, and 0.99 for the confidence sections for this population sample.21

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Table

In January 2014, with grant support from the American Association of Nurse Practitioners, HF S2S was replicated in a cardiology practice with eight geriatric participants from an Appalachian population over a 6-month period.23 The project was approved by the university's Institutional Review Board. This number was limited due to severe weather during recruitment. A significant mean difference in pre- and post-HF S2S was reported for HF hospital admissions (3.06 [7], p < 0.02) and a significant improvement in HF management of participants (p = 0.02) using the SCHFI.22,23

There was no statistically significant change noted in maintenance or confidence. Furthermore, a post hoc power analysis was performed on the SCHFI scores using SPSS version 15. The power for the management score was the same as the house call practice (0.95), and lower for the maintenance (0.16) and confidence (0.37) scores for the cardiology practice population.

Currently, a study is underway at three HF clinics in the Midwest using the HF S2S program toolkit by an NP. This study began recruitment of 100 participants in November 2015 to help identify predictive variables, including demographic, HF hospital admission rates, and HF S2S intervention response (demonstrated ability to increase self-care behaviors) using the HF S2S toolkit. All of the NPs in the current and previous studies provided direct care for patients with HF.

The feedback from NPs and patients who participated in the HF S2S pilots was used in the development of the toolkit. This toolkit was designed to be used as a one-on-one counseling strategy between NPs and patients in an outpatient practice setting. The toolkit includes a detailed implementation process to be used with patients with HF. Healthcare providers may use the HF S2S toolkit or adapt it for their own purposes citing the author.

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Discussion

The HF S2S toolkit was developed through formative research and feedback from NPs and patients. The feedback from NPs frequently included that a formalized educational tool would be beneficial for assisting with one-on-one counseling during office visits. The results from the two pilot studies (in decreasing HF hospital admissions and improving self-care behaviors across two practice settings and diverse populations) indicate an effective operational toolkit.21,23 These findings are reinforced by the positive feedback from the NPs implementing this program. Furthermore, given these findings, the toolkit appears to be effective at enhancing one-on-one counseling and improving the HF management of patients with worsening HF symptoms.

Since the HF S2S toolkit was developed in 2011, an updated search was conducted using CINAHL with full text and MEDLINE with full text (July 2011 to August 2016) and the Cochrane Library (2012 to 2016). Due to the current use of HF S2S in research studies, the combination of keywords and subject headings in all databases included “heart failure,” “self-care,” and “hospital admissions.” The studies were limited for English language, humans, and peer-reviewed.

Inclusion criteria included patients with HF of all ages, self-care interventions, and both outcome measurements of self-care behaviors and hospital admissions. CINAHL/MEDLINE and the Cochrane Library search resulted in 18 and 8 hits, respectively. The titles and abstracts of these articles were reviewed with only one relevant article identified from the Cochrane Library.24

Inglis and colleagues provide a systematic review protocol to review and quantify the potential benefits of online mobile education in patients with HF.24 Outcome measures stated in this review relevant to the HF S2S program include HF knowledge, self-efficacy, medication adherence, and HF hospitalizations. There has been no update to the HFSA nonpharmacologic guidelines or AHA expert statement since the search in 2011.4,11

Studies support the inclusion of self-care programs in outpatient practice settings with direct care providers.21,23,25 In addition, the ACA has emphasized that policy changes in the future are driving the importance of value-based care. NPs as direct care providers will facilitate improvement of self-care behaviors and reduce hospitalizations.4

Additional dissemination of the toolkit, continuing to review the literature, and future research using the HF S2S toolkit can have substantial impacts on HF hospital admissions and self-care behaviors. To this end, some realistic strategies can be employed in the near future to improve patients' HF self-care. Some possibilities include:

  • Identifying opportunities to incorporate self-care as a routine part of practice in academic training programs for NPs
  • Engaging leaders and community partners to influence healthcare systems to use this program as a transition mechanism for improved patient outcomes
  • Promoting partnerships with corporate systems and venture capitalists to move HF S2S into the online era
  • Working with interprofessional teams toward the future application of this toolkit
  • Incorporating this into an opportunity to collect data on behavioral health through electronic medical record technology with insurance companies paying for the cost.

In future research trajectories, the use of technology needs to be explored as an innovative means to empower patients in self-care activities and improve provider communication. This aligns with recent developments in healthcare technology and practice with other chronic diseases.26,27 In the future, integration of HF S2S into a mobile app with the functionality to inform, instruct, record, prompt, remind, and improve direct care provider communication of patients with HF via numerous technology features would be innovative.

Patient engagement with self-care can promote improved provider and patient communication that has not been demonstrated with current time-consuming telehealth and monitoring systems. With the rise of technology, it will be critical to the future sustainability and continued use of the HF S2S toolkit to explore mobile app development.

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Limitations

Despite the rigorous background work invested in the development of the toolkit, the evaluation evidence to date has a number of limitations. Most critically, no comparative outcome study with a control group has been conducted. Additionally, the lack of a longitudinal observation on the outcomes (change in practice behavior of NPs, reduction in risk ratio, predictors of self-care behavior improvement) and the small sample size are limitations of this program.

Without a controlled trial of the toolkit and more diverse sample, a definitive statement that the improvements in HF knowledge and patient outcomes are attributable to the toolkit and not to other potential confounding variables cannot be stated. The lack of longitudinal observation limits the ability to determine lasting positive effects of the toolkit over time. Furthermore, due to the small sample and specific populations studied, these findings are not generalizable to the HF population. The implementation of the toolkit in longitudinal, randomly controlled studies with larger sample and varied practice settings is recommended to address these limitations.

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Empower and engage

The HF S2S toolkit is a promising program for improving self-care behavior with HF and decreasing HF hospital admissions. The toolkit was developed based on a process of translating research, clinical practice guidelines, and EBP into the practice arena to add to the self-care of HF knowledge base and improve patient outcomes. This toolkit empowers patients and engages the NP toward improved patient outcomes by focusing on the key areas of HF self-care behaviors and decreased healthcare utilization. The HF S2S toolkit is poised to have a significant and enduring impact on HF outcomes.

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HF S2S program toolkit

Program goal: To empower HF patients to achieve optimal heart health and independence through self-care maintenance, management, and confidence

Provider objective: To assist providers in the education of patients in HF self-care

Materials needed: HF S2S calendar/journal and weight scale

Instruction methods: Patient self-paced and one-on-one NP counseling

Step one: Complete and update information on calendar:

  • Provider information on first page with phone numbers
  • Medication list and describe purpose for all medications on back page
  • Begin “month” and fill in dates

Step two: Calendar recordings (maintenance):

  • Daily weights
  • Level of swelling
  • Medication administration
  • Other (tests, provider appointments, home health visits)
  • Share calendar with all caregivers and other providers
  • Review HF S2S calendar at each visit

Step three: HF education

  • NP: Quick review of HF education on calendar pages
    • – Basic knowledge (maintenance/management)
    • – Daily weights/record (maintenance)
    • – Worsening signs/symptoms (management)
    • – Action plan (management)
    • – Sodium intake (maintenance)
    • – Fluid intake (maintenance)
    • – Medication administration (maintenance)
    • – Activity (maintenance)
    • – Prevention/lifestyle (maintenance)
    • – Pulling it all together (confidence)
    • – Ongoing one-on-one counseling
  • Patient: Self-paced learning
    • – Call with questions about the program
    • – Develop and adjust HF management action plan with provider
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Keywords:

heart failure; HF; hospital admissions; self-care; toolkit

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