Outcomes of an Interdisciplinary Transitional Care Quality Improvement Project on Self-Management and Health Care Use in Patients With Heart Failure

Abstract

Heart failure (HF) accounts for most U.S. Medicare hospital admissions. The purpose of the current study was to evaluate the effectiveness of a care transitions quality improvement (QI) intervention on self-management and readmission rates in older adults with HF. A quasi-experimental, descriptive study was conducted with 66 patients with HF in three medical units in a 489-bed Midwestern acute care hospital. The intervention included a nurse coach visit and follow up, pharmacy medication education and reconciliation, and HF clinic referral. Outcomes were assessed within 48 hours of admission and 30 days after discharge using the Self-Care of Heart Failure Index and medical record review. Following implementation, readmission rates decreased from 24% to 13%. Participants demonstrated a greater improvement in use of self-management strategies to control symptoms than the non-intervention group (p < 0.02) and more readily identified their symptoms of HF (p < 0.04). The evolution of population health, with increasing numbers of older adults living at home with complex chronic conditions, will require establishment of active partnerships among pharmacists, physicians, nurse specialists, home care nurses, and patients. [Journal of Gerontological Nursing, 43(1), 23-31.].

The Experience of Chronic Illness Transitional Care: A Qualitative Systematic Review

“…Patients indicated challenges in learning self-management skills and applying self-management at home. Several clinical trials have recommended self-management strategies during transitions (Aboumatar et al, 2019; Hoover et al, 2017). These studies demonstrated the importance of self-management education before discharge, a nurse-coach visit, and follow-up self-management training.…”

Care for people with heart failure after hospital discharge: integrative review / Cuidado à pessoa com insuficiência cardíaca após alta hospitalar: revisão integrativa

“…In this sense, some articles showed about the guidance regarding pharmacological treatment, 16,[25][26][27][39][40][41][42][43] of which most pointed out the importance of the participation of the pharmacist in counseling people with HF and their families. [25][26]39,[41][42][43][44] It is believed that some problems resulting from low understanding of pharmacological treatment are solved by offering written instructions, with easy to understand language, emphasizing the name of the medications, dose, route and time of administration, indications and possible adverse reactions.…”

“…However, there was no consensus about the most appropriate time frame for this consultation. 19,23,26,28,40,44,[49][50][51][52] Although there is no consensus about the deadline for the post-discharge consultation of people with HF, it is suggested that it should be performed between seven and 14 days after discharge, not exceeding 30 days. 26,40,[49][50][51] In addition, to contribute to improvements in post-discharge follow-up, appointments can be scheduled near the residence of the person with HF and provide ways for them or their relatives to be reminded about the day and time of the scheduled consultation.…”

“…19,23,26,28,40,44,[49][50][51][52] Although there is no consensus about the deadline for the post-discharge consultation of people with HF, it is suggested that it should be performed between seven and 14 days after discharge, not exceeding 30 days. 26,40,[49][50][51] In addition, to contribute to improvements in post-discharge follow-up, appointments can be scheduled near the residence of the person with HF and provide ways for them or their relatives to be reminded about the day and time of the scheduled consultation. 44 It is necessary to consider that, to ensure proper monitoring of the disease, there is a coherent communication between the various levels of complexity through which the person with HF goes through.…”

“…Moreover, the authors mention the importance of involving the caregiver in the treatment plan in cases where it is necessary. 40,48 Added to this is the need for the person with HF and his family members to be clear about the treatment possibilities. The importance of communication between professional and patient/family members is highlighted, particularly with regard to end-of-life preferences.…”