Pilot Program to Improve Self-Management of Patients with Heart Failure by Redesigning Care Coordination

Abstract

Objectives. We tested both an educational and a care coordination element of health care to examine if better disease-specific knowledge leads to successful self-management of heart failure (HF). Background. The high utilization of health care resources and poor patient outcomes associated with HF justify tests of change to improve self-management of HF. Methods. This prospective study tested two components of the Chronic Care Model (clinical information systems and self-management support) to improve outcomes in the self-management of HF among patients who received intensive education and care coordination during their acute care stay. A postdischarge follow-up phone call assessed their knowledge of HF self-management compared to usual care patients. Results. There were 20 patients each in the intervention and usual care groups. Intervention patients were more likely to have a scale at home, write down their weight, and practice new or different health behaviors. Conclusion. Patients receiving more intensive education knew more about their disease and were better able to self-manage their weight compared to patients receiving standard care.

<br /><br /> GESTÃO DO AUTOCUIDADO DO DOENTE COM INSUFICIÊNCIA CARDÍACA: INTERVENÇÃO ENFERMAGEM REVISÃO INTEGRATIVA<br /> MANAGEMENT OF SELF-CARE OF PATIENTS WITH HEART FAILURE: INTERVENTION NURSING INTEGRATIVE REVIEW

“…O doente com insuficiência cardíaca sofre alterações a nível do seu autocuidado e para que haja melhoria na qualidade de vida é fundamental que estes doentes tenham conhecimento da sua doença e consigam reconhecer os sinais e sintomas de agravamento (6,7) . Só com este conhecimento conseguem fazer uma gestão adequada do autocuidado (20) . É também tendo como base este conhecimento que se evitam os reinternamentos e o recurso à urgência por descompensação (11,20) .…”

“…Só com este conhecimento conseguem fazer uma gestão adequada do autocuidado (20) . É também tendo como base este conhecimento que se evitam os reinternamentos e o recurso à urgência por descompensação (11,20) .…”

“…Heng-Hsin et al,2013 16 Ávila et al,2013 17 Näsström et al, 2015 18 Marcuccilli et al,2013 19 Shaw et al, 2013 20 Tsai et al…”

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

“…One study 138 did not (described below). Two studies 105,140 found that care planning during and after the transition from secondary to primary care reduces readmission rates, and another two 86,105 that having operational facilitators to support care planning reduced readmission rates.…”

“…This intervention did indeed make patients more likely to monitor their weight and change their health behaviours, but no less likely to be admitted or re-admitted to hospital. 140 A SR 105 of transitional care interventions found that three components of care were associated with reduced short-term admission rates: (1) care co-ordination by a nurse (most frequently a registered nurse or advanced-practice nurse), (2) a home visit within 3 days and (3) communication between the hospital and the primary care provider. Most of the interventions in the review that reduced intermediate-and long-term readmissions involved care co-ordination.…”