Heart failure (HF) affects 5.1 million people and is responsible for one in nine deaths. It is estimated that more than half of the people diagnosed with heart failure die within five years of diagnosis. Approximately 20% of Medicare beneficiaries are readmitted within 30 days of discharge.1 Heart failure occurs when the heart is too weak to effectively pump blood through the aorta, causing blood to pool in the heart and surrounding vasculature. Symptoms of heart failure include dyspnea, fatigue, weight gain and edema. The diagnosis of heart failure relies on a variety of tests and symptomatology, such as: B-type natriuretic peptide (BNP), echocardiogram and chest x-ray. Treatment modalities for the management of HF include pharmacological and non-pharmacological interventions.2
Cleland, et al.3 conducted a randomized controlled trial examining the effects of home tele-monitoring (HTM), nurse telephone support (NTS) and routine “usual” hospital care (UC) on improving outcomes in HF patients who were at high risk for hospital readmission or death. Eligible participants were ready for or recently discharged from hospitals in Germany, the Netherlands and the United Kingdom. According to Cleland et al.,3 “inclusion criteria consisted of hospital admission due to worsening HF lasting greater than 48 hours within the last six weeks, ejection fraction (EF) <40%, and left ventricular (LV) end-diastolic dimension >30mm/m and receiving furosemide at a dose > 40mg/day or equivalent.” A total of 426 patients were randomly assigned HTM, NTS, or UC.
A HF nurse specialist contacted the NTS GROUP once a month to provide patient education and then collaborate with the primary care physician (PCP) in regard to patient progress. Participants were advised to call the HF clinic with questions or concerns related to their HF diagnosis. The HTM group had their heart rate, rhythm, weight and blood pressure monitored twice daily. The UC group followed the standard of care implemented by their PCP. The study took place over a time span of 450 days. Due to a large difference in mortality between the UC group and those assigned to HTM or NTS, an interim analysis was conducted and the trial was brought to a close. Follow up was allowed to continue and the days hospitalized or lost to death were examined over a total of 240 days. Cleland et al.3 summarizes that “19.5%, 15.9% and 12.7% of days were lost as the result of death or hospitalization for UC, NTS and HTM. Patients randomly assigned to UC had a higher one-year mortality rate (45%) than patients assigned to receive NTS (27%) or HTM (29%).” Findings of this study reported a similarity between the numbers of admissions and mortality between the HTM and NTS group.
A U.S.-based study conducted by Hall and Morris consisted of 105 patients who had been newly diagnosed with HF, had an exacerbation of HF, history of HF with admission in the past six months or treatment for pneumonia, shortness of breath or myocardial infarction in the past six months.4 The participants received home care services from Athens Regional Home Health (ARHH), servicing the area of Atlanta, Ga., at the time of enrollment.4 The objective of the study was to see if chronic disease management education provided by RNs, coupled with bio-impedance monitoring, a method of identifying fluid increases within the chest, could reduce the acute hospitalization rate and the 30-day hospital readmission rates for HF exacerbation to below half the national rate of 25%.4
To implement the chronic disease management education, a training book for the study participants was created with education materials structured to meet the needs of the home care patient. The study participant education consisted of an overview of HF symptoms, daily weight monitoring, managing diet, fluid intake and medication education. After implementation, the study participants received front-loading home care visits, followed by more frequent and shorter visits to reinforce and improve remembrance of education materials. In addition, procedures to monitor bio-impedance were implemented.4
The results showed a decrease in acute hospitalization rate from 32% to 13%.4 The 30-day hospital readmission rate of 8% was below the national rate of 25%. Furthermore, the participants, along with their families or caregivers, reported an improvement in their quality of life and satisfaction. Cause and effect cannot be confirmed by the results of this study since the sample of participants was selected from the same home health care system and the design was not a randomized control trial (RCT). An RCT would further support the findings of this study, as it would infer a cause and effect relationship. A review of these studies show a need for further research that would posit a connection between RN driven tele-monitoring programs and the reduction in readmission rates among HF patients.
Most literature indicates that HF patients benefit from HTM in respect to readmission than patients who received UC and pre-discharge education or “teach back.”3,4 Strong patient education and frequent monitoring by a HF trained nurse showed a significant decrease in readmission rates and mortality reduction compared with the UC received in the hospital setting.3 In contrast, Reilly et. al.,5 suggests that when patients and their family members are educated on diet restrictions, medication regimens and the pathophysiology of HF, adherence improves and there is a reduction in ED visits and hospitalizations.
Rocha et. al.,6 evaluated the results of adherence in a HF program that was administered by multidisciplinary staff members comprised of physicians (internists, cardiologists, psychiatrists), nurses, social worker, nutritionist and a statistician. The participants were provided with education materials, and the results of this study documents that adherence to HF programs is closely related to the support system the patient had in the outpatient setting. Patients who were socially isolated without family members or unofficial caregivers were more likely to drop out of the program.6 There was not a relationship between drop-out rates and education level. In fact, there was an inverse relationship. Patients who did not complete primary school were less likely to drop out of the program; the reason for this relationship is unclear.
Bradley et. al.,7 posits that when hospitals collaborate with primary care entities, readmission rates are lower. This study also notes that teaching hospitals and hospital systems are shown to have higher readmission rates than smaller, non-teaching hospitals. This study also examined the relationship between medication reconciliation by staff nurses, discharge appointments made prior to the patient leaving the hospital and follow up calls, noting these were associated with reduction in readmission rates. The summary of this study emphasized that strong communication between the hospital and primary or community provider was the connection to reducing readmissions.7 The common denominator in all of the studies reviewed is the relationship between patient education, social support and interdisciplinary communication in order to reduce readmissions in HF patients. All studies are clear that there needs to be a multidimensional approach to reducing readmissions of HF patients. These studies also agree that patient management beyond discharge is a great challenge and one that must be accomplished by the support of multidisciplinary team members. The objective of this paper is to examine the role in which the NP plays in affecting the struggle between HF readmission rates and patient success and well being.
A study conducted by Grady et. al.,8 examined the relationship between NP managed HF clinics and readmission reduction and reduction in ED visits. The role of the NP was to manage the patient in the outpatient setting. Their role included frequent follow up visits, medication monitoring, increased availability (if the patient wished to phone in with questions), tele-monitoring, and inpatient rounding in some programs. The NP had a cardiologist available for consultation if needed. The study reported a decrease in ED visits by 80%, and a reduction of readmissions by 60%. The connection between the utilization of an NP in this role suggests a benefit for not only the patient but also the healthcare facility that struggles to reduce readmissions.8 The costs associated with outpatient care are considerable; however, this cost is offset by the reduction in costs associated with high readmission rates. There is clear inference that an HF clinic reduces readmission rates, and the role of the NP in relation to this endeavor continues to be investigated. There is a need for further studies to support the literature. A limitation in literature was seen in the lack of consistent evidence that the NP is truly an asset in this arena of healthcare. Secondly, the literature is inconsistent in its definition of the exact role of the NP in this setting.
Hutt et. al.,2 compares the clinical management of patients with chronic diseases by an NP versus a medical doctor. The findings of this study conclude that there is no statistically significant difference in patient outcomes. In fact this study shows that patients who were cared for by an NP had higher rates of satisfaction in regard to the care they received. The implications of this study could advocate for the utilization of the NP as lead in reducing readmission rates of HF patients.2
Cris Amato is a staff nurse at Jersey City Medical Center in Jersey City, N.J.
1. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. https://www.nice.org.uk/guidance/cg108.
2. Stanik-Hutt J, et al. The Quality and Effectiveness of Care Provided by Nurse Practitioners. The Journal for Nurse Practitioners. 2013;9(8):492-500. doi:10.1016/j.nurpra.2013.07.004.
3. Cleland JGF, et al. Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death: The Trans-European Network-Home-Care Management System (TEN-HMS) Study. ACC Current Journal Review. 2005;14(9). doi:10.1016/j.accreview.2005.08.225.
4. Hall P, Morris M. Improving Heart Failure in Home Care with Chronic Disease Management and Telemonitoring. Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional. 2010;28(10):606-617. doi:10.1097/nhh.0b013e3181f85d14
5. Reilly CM, et al. Development, Psychometric Testing, and Revision of the Atlanta Heart Failure Knowledge Test. The Journal of Cardiovascular Nursing. 2009;24(6):500-509. doi:10.1097/jcn.0b013e3181aff0b0.
6. Rocha PA, et al. Predictors of Dropout From a Multidisciplinary Heart Failure Program. The Journal of Cardiovascular Nursing. 2009;24(6):475-481. doi:10.1097/jcn.0b013e3181b2c418.
7. Bradley E, et al. Hospital Strategies Associated With 30-Day Readmission Rates for Patients With Heart Failure. Circulation: Cardiovascular Quality and Outcomes. 2013;6(4):444-450. doi:10.1161/circoutcomes.111.000101.
8. Grady K, et al. Team Management of Patients With Heart Failure: A Statement for Healthcare Professionals From the Cardiovascular Nursing Council of the American Heart Association. Circulation. 2000;102(19):2443-2456. doi:10.1161/01.cir.102.19.2443.