Coordinated‐Transitional Care for Veterans with Heart Failure and Chronic Lung Disease

Abstract

OBJECTIVES Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30‐day hospital readmissions nationwide. The Coordinated‐Transitional Care (C‐TraC) program is a telephone‐based, nurse‐driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non‐VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C‐TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. DESIGN We used the Replicating Effective Programs model to guide the implementation. The C‐TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. SETTING The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. PARTICIPANTS Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. MEASUREMENTS A total of 43 (15.8%) C‐TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90‐day hospital admission, and discharge diagnosis. RESULTS Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24‐.89). CONCLUSION The program was financially sustainable. The total cost of care in the 30‐day postdischarge period was $1842.52 less per C‐TraC patient than per controls, leading the medical center to sustain and expand the program.

Transitional Care Interventions for Patients with Heart Failure: An Integrative Review

“…All studies conducted transitional care interventions for patients with HF. Regarding research design, there were 10 RCTs [16,21,22,24,28,29,32,33,36,38], two quasi-experiments [23,40], two pre-and post-tests [17,26], six cohort studies [18,19,27,34,35,37], and five prospective studies [20,25,30,31,39]. Although it was necessary to establish controls to verify the effects of transitional care interventions, in six of the 25 studies [17][18][19][20]26,39], there was no comparative control group set up to verify the effectiveness of transitional care interventions.…”

“…Although it was necessary to establish controls to verify the effects of transitional care interventions, in six of the 25 studies [17][18][19][20]26,39], there was no comparative control group set up to verify the effectiveness of transitional care interventions. In 15 of the 25 studies, the primary intervention providers were nurses [16,[20][21][22][23][24][25][26][28][29][30]32,33,37,38], including advanced practical nurses, clinical nurse specialists, research nurses, nurse practitioners, cardiac nurses, registered nurses, nurse case managers, registered nurse case managers, and liaison nurses. A multidisciplinary team served as the primary intervention provider in five studies [17,31,35,36,39].…”

“…The sample size ranged from 38 [24] to 3462 [19], and the average patient age was between 65 [36] and 82 years [27,30]. The percentage of males ranged from 35% [34] to 97% [37], but three studies [20,26,32] did not report sex.…”

“…Subjects presented with various HF types: two studies reported on end-stage HF [28,32], three on chronic HF [16,23,33], two on congestive HF [21,37], one on decompensated HF [29], and the remaining 17 on HF [17][18][19][20]22,[24][25][26][27]30,31,[34][35][36][38][39][40]. To identify HF severity, we considered the New York Heart Association (NYHA) class and left ventricle ejection fraction (LVEF).…”

“…One study reported B-type natriuretic peptide level >200 ng/mL [25], and two studies reported HF with reduced or preserved ejection fraction [17,18]. The remaining 12 studies [20,23,26,27,[30][31][32][33]35,[37][38][39] did not report the participants' severity of HF.…”