1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce read-mission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse-driven home health care program. The comprehensive intervention resulted in a marked reduction in 6-month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow-up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.

Congestive heart failure (CHF) is a public health problem of enormous national significance. CHF currently afflicts five million Americans and is expected to increase at a rate of more than 500,000 new cases per year.1–4 Therapeutic advances in the treatment of CHF, coupled with an aging US population, have fueled the continued increase in both the incidence and prevalence of heart failure over the past several decades. CHF is now the most common diagnosis-related group in the Medicare population; up to 80% of all CHF patients are over the age of 65 years. CHF is associated with extremely high readmission rates, approaching 50% by 6 months, at an estimated cost of $7000 per readmission.5–12 Given that approximately 700,000 Medicare recipients are discharged annually with a diagnosis of CHF,13 the economic burden for CHF readmissions is staggering. With pressure to reduce hospital costs and inpatient length of stay (despite an increasingly complex, elderly patient population), much of the burden of care has shifted to the outpatient setting, with little time available for inpatient education or comprehensive coordinated discharge planning. Lack of a comprehensive approach to CHF management involving careful inpatient education, discharge planning, and coordinated delivery of outpatient care has been cited as a major reason for the continued high rates of hospital readmissions for CHF.1

Multidisciplinary disease management programs can substantially reduce readmissions for CHF, but these interventions have typically included medical management. Thus, the key element (s) of a successful program involving education, discharge planning, and transitional care to the outpatient setting has been difficult to quantify.

We utilized an experienced cardiac nurse educator to coordinate a targeted inpatient CHF education program with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated, nurse-driven home health care program. We postulated that more intensive inpatient education, coupled with coordination of discharge planning with immediate outpatient reinforcement, would significantly improve readmission rates and decrease overall utilization of medical services after an index CHF admission compared with standard therapy.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Patient Population. Subjects were considered eligible for the study if they were over 50 years of age, admitted with the primary diagnosis of CHF to Bridgeport Hospital, Bridgeport, CT, and able to participate in home health care postdischarge. Between January 1, 1996 and March 31, 1997, consecutive admissions for CHF were screened daily by a dedicated cardiac nurse educator to identify patients meeting eligibility requirements. The inclusion criteria were as follows: primary diagnosis of CHF, symptoms consistent with the diagnosis of CHF, and radio-graphic evidence of CHF (an ejection fraction <40% by echocardiogram or ventriculography was required if radiographic evidence for CHF was equivocal). Exclusion criteria included the following: refusal to participate in inpatient education or home health care, myocardial infarction within the prior 12 weeks, unstable angina, confusion, planned discharge to an extended care facility, more than five significant comorbidities, renal failure requiring dialysis, impending cardiac surgery, or continued New York Heart Association (NYHA) class IV CHF despite maximal medical treatment.

The control group consisted of subjects with the primary diagnosis of CHF who met the inclusion criteria over the same time period, but did not receive the study intervention. Due to the time constraints of the sole nurse educator, many of the CHF subjects over the study period did not receive active intervention; these patients served as controls. Control subjects received usual inhospital care and education from the regular nursing staff according to a standard CHF pathway, and routine postdischarge home health care without benefit of either inpatient interaction with the cardiac nurse educator, telephone follow-up, or a specialized outpatient CHF education program.

Study Intervention. A comprehensive community hospital-based heart failure program was developed coupling targeted inpatient education and discharge planning with subsequent coordinated home care and telephone follow-up. The intervention was aimed at improving basic care domains for chronic illness, including patient knowledge of disease processes, early symptom recognition, understanding the relationship between health behaviors and medication, and obtaining appropriate follow-up to improve quality of life. Initially, the patient's understanding of the domains was assessed to identify knowledge gaps. Formal, individually targeted patient education was provided by a cardiac nurse educator in an attempt to correct any prospectively identified deficiencies.

An inpatient clinical pathway was developed based on a 4-day length of stay. It detailed a structured program of disease management, education, and activity progression. The pathway prompted an education session to be conducted at the bedside by a cardiac nurse specialist, a physical therapy evaluation, and a dietary consult. The main purpose of the intervention was to provide participants with information aimed at improving disease management ability, functional capacity, and quality of life.

For the initial phase, intervention subjects received an hour-long, in-depth educational session conducted by the cardiac nurse educator within the first several days of hospitalization after medical stabilization. This face-to-face interview was supplemented by a packet of written information to reinforce heart failure education. A commercially prepared brochure entitled “Congestive Heart Failure—Living With Heart Failure Guidelines,” (Krames, Yardley, PA) was developed specifically for the program. The cardiac nurse educator reinforced the educational visit with a brief follow-up visit before discharge.

The intervention subjects were also interviewed inhospital by a registered dietitian, for an average of 30 minutes, and given personalized instructions developed by the nutritional services department. A brief follow-up visit by the dietitian before discharge reinforced dietary concepts and compliance with a sodium-restricted diet. Each intervention subject was assessed by a physical therapist during the hospital stay to evaluate functional capacity; these visits lasted approximately 30 minutes per participant. An individualized activity plan was developed to gradually improve exercise tolerance through ambulation and low-level exercises. Each patient received a follow-up visit from the physical therapist before discharge for assessment of activity progression, averaging approximately 15 minutes. In addition, all disciplines averaged approximately 15 minutes for chart review before the intervention.

Comprehensive discharge preparation was a critical element in the intervention group. All subjects in the intervention group received comprehensive information related to exacerbation of heart failure and appropriate responses. Discharge planning was coordinated with home health care nurses specifically trained in CHF management by the cardiac nurse educator. Home health care nurses immediately reinforced the concepts of the inhospital education program. Further, in an attempt to promote compliance with weight monitoring, intervention subjects were given a scale before discharge if they were unable to procure one on their own.

A 6-week home care clinical pathway was developed as an extension of the inpatient pathway. This allowed for 6–20 visits, determined by the patient's progress, to be conducted by the home care nurses who had received specialized cardiac training. The objective for each home visit included a formal cardiac evaluation and patient education, as well as advancing activity levels. The goal of the nursing visits was to empower patients to contribute to their care and enable them to detect subtle changes in their cardiac status that might presage an exacerbation of their disease. The pathway enabled the home care nurse to concentrate on individualized educational objectives for each patient with continual assessment of patient compliance with diet, medication, and weight monitoring. Patients were encouraged to ambulate daily and to perform low-level exercises. Pulse tak-ing and symptoms of exercise intoler-ance were emphasized to promote safe activity progression.

Subjects in the intervention group were interviewed by telephone by a nurse case manager within 2 weeks of hospital discharge. Subjects responded to ten questions designed to assess symptom control, medication compliance, dietary adherence, and activity capacity; these calls averaged 15 minutes in length. The attending physician was notified of specified weight gain parameters, dyspnea, increasing pedal edema/abdominal girth, or chest pain. The home health agency was notified if the patient reported increased difficulty performing activities of daily living, noncompliance with diet or medication, or lack of family support.

Control subjects received CHF education from the regular nursing staff, but did not benefit from formal one-on-one interaction with the cardiac nurse educator. Dietary and physical therapy consults were left to the discretion of the attending physician. Telephone contact with control subjects was not routinely performed after discharge. Home health care was carried out by the same home health care agency as for the intervention subjects, but by nurses who did not receive formal CHF training regarding the home care pathway from the cardiac nurse educator.

Data Collection and Follow-up. For the intervention patients, demographic and clinical information was obtained during the face-to-face session with the cardiac nurse educator. Additional clinical information and test results were abstracted prospectively from patient charts. Data abstraction for control patients was performed by cardiac home health care nurses during their intake interview and during medical record review of the index admission for CHF.

Six-month readmission rates were ascertained prospectively by the home health care nurses from patient interviews. Hospital discharge summaries were reviewed to confirm the diagnosis of CHF at the time of readmission. Costs were calculated using the Transition Accounting System (Transition Accounting Systems, Inc., Boston, MA) for readmissions to Bridgeport Hospital.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Study Sample. A total of 276 subjects were admitted with the primary diagnosis of CHF during the study period. One hundred twenty patients were not eligible for home health care or failed to meet inclusion criteria due to recent myocardial infarction or unstable angina, continued NYHA class IV CHF, confusion, impending cardiac surgery, or planned discharge to an extended care facility. Of the 156 subjects meeting inclusion criteria, 60 patients were randomly screened by the nurse educator. Fifty-six subjects consented to enrollment in the heart failure program. Twelve patients were referred to outside home health care agencies that did not participate in the prescribed CHF outpatient clinical pathway and were thus excluded from analysis. The 44 remaining patients who completed the entire inpatient and outpatient CHF protocol constituted the intervention group.

The remaining 96 CHF patients were eligible for home health care services and were considered for inclusion in the study. Twelve patients had more than five comorbidities and were excluded. Seven patients were excluded for functional status impairments, including bed-bound patients and those with contractures. The remaining 77 patients receiving usual inhospital care and subsequent routine home health care without a specifically designed CHF program constituted the control group.

Demographic features are shown in Table I. The two groups were well matched for all parameters except social support. For the entire cohort, the mean age was 78.5 years. Thirty-eight percent were men and 61% were women. Eighty-two percent were Caucasian. In terms of social support, 50% of intervention subjects lived alone, compared with 27% of control subjects (p>=0.01), which resulted in fewer willing partners at home in the intervention group as compared with controls (43% vs. 66%; p=0.02). Associated comorbidities were equally distributed between the two groups and are listed in Table I. Subjects in both groups were fully oriented or displayed only mild memory impairment and were felt to be suitable for inclusion. There were no significant differences in medication use between the two groups at discharge (Table II).

Table I. Demographic Information
 Patient Group 
 Intervention (n=44)Control (n=77)P Value
Mean age (yr)81770.8
Gender (n [%])   
Race (n [%])  
Marital status (n [%])   
Living condition (%)   
With unwilling person6.86.50.9
With willing person43660.02
Health care provider (%)   
Comorbidities* (n [%])   
*Comorbidities include: Alzheimer's disease, atrial fibrillation, cerebrovascular disease, chronic obstructive pulmonary disease, coronary artery disease, decubital ulcers, depression, diabetes, gastrointestinal bleeding, hip fracture, malignancy, peripheral vascular disease, pneumonia, pulmonary embolus, renal failure, urinary tract infection, valvular disease, and venous thrombosis
Table II. Medication Profiles at Discharge
 Patient Group (%) 
MedicationInterventionControlp Value
ACE inhibitor81.870.10.16
β Blocker29.517.90.14
Aspirin or warfarin81.867.50.07
ACE=angiotensin-converting enzyme

The primary outcome of the study was hospital readmission rates. The hospital readmission rate for the control group that received usual care was nearly four times that of the intervention group (Figure). Intervention subjects had an 11.4% readmission rate within 6 months, compared with a 44.2% readmission rate in control subjects (p>=0.01). We hypothesize that 14 readmissions were avoided in the intervention group (19 read-missions were expected at the 44% control readmission rate vs. the five readmissions observed in the intervention group). Given an average total hospital cost for a CHF readmission of $7000, a further $91,000 savings would be expected with a sample size of 44 patients. Thirty-day readmission rates were reduced as well in the intervention group (6.0% vs. 22.1% in the control group; p>=0.01).


Figure Figure. Distribution of readmissions over 6 months. The 6-month readmission rate for congestive heart failure in the control group was nearly four times that of the intervention group (44% vs. 12%; p=0.01).

The secondary outcome was utilization of home health care services. The initial cost of the inhospital component of the intervention is shown in Table III. Hospital costs for program implementation were $6960 for all 44 intervention subjects ($158 per subject), excluding the planning phase. Home health care utilization for the 6-week program is shown in Table IV. The number of recorded visits reflects the average for each patient per discipline. There was a significant increase in the number of both skilled nurse visits and home health aide visits required in the control group. The control group required nearly 50% more skilled nurse visits and over twice as many visits from home health aides.

Table III. Costs for Inhospital Program Implementation
DisciplineTime Spent (min)Hourly Rate ($)Total for 44 Patients ($)
Cardiac RN75502750
Physical therapist60502200
Scales for 12 patients 30/patient360
Total  6960 (158/patient)
Table IV. Home Care Utilization: Number of Visits
 Patient Group
Skilled nurse1521.0
Home health aide1432.0
Physical therapist2.253.60
Occupational therapist0.100.40
Medical social worker0.603.20

Decreased utilization of skilled nurses and ancillary personnel resulted in significant reductions in outpatient costs in the 6 weeks following discharge in the intervention group compared with controls. The average total 6-week cost savings for home health care for each subject in the intervention group was $1541. This cost saving was a direct result of decreased utilization of both skilled and unskilled home health care follow-up services. The total cost saving for all 44 intervention subjects was $67,804.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

We report that a multidisciplinary CHF program coordinating inpatient and outpatient care through comprehensive discharge planning can dramatically reduce costs and readmissions. Stressing patient education and self-empowerment, while providing patient support and immediate feedback, markedly improved patient outcomes without changing any medical management components. Reductions of nearly 75% in 6-month CHF readmission rates are compatible with reductions seen with more intense case management programs. Our program was similar to that described in a 2002 report emphasizing patient education and empowerment, in which Krumholz et al.14 noted similar reductions in readmission rates and lower total costs by utilizing frequent telemonitoring in addition to inhospital education. Although our study relied more on nurse-based home health care intervention, there was still a significant reduction in total costs associated with the index admission for CHF.

Our study was also similar to that of Jaarsma,15 in which a brief inhospital nursing encounter for education and social support was followed by a home visit by the same nurse to each intervention patient. There was no significant reduction of resource utilization, however, in the Jaarsma study. Several other nurse-directed multidisciplinary home-based interventions have been associated with 40%–56% reductions in CHF admission, but these studies relied on intensive medical management, while in our study, medical management was left to the physician's discretion. A literature review reempha-sized the importance of comprehensive discharge planning with postdischarge support for elderly patients with CHF. Readmission rates and quality of life are significantly improved in intervention patients without an increase in costs.1 Survival may also be improved with better support. The success of these programs is likely due to improved patient compliance with diet, exercise, and medications through education, self-empowerment, and social support.

Several important outcomes are apparent from this study. First, the duration of home care follow-up for the intervention group was shorter. Home care utilization was more cost-effective for the intervention group, because intervention patients averaged fewer visits from all disciplines. The lower cost of total care stemming from the index admission in intervention patients was driven by reduced home health care costs with only minimally increased inhospital costs.

The overall readmission rate for the control group was more than twice that of the intervention group. Furthermore, the readmission rate was also higher for the control group at 2 weeks, 30 days, 60 days, 90 days, and 6 months postdischarge. The 12% readmission rate at 6 months achieved by the intervention group was lower than the 29%–47% readmission rates found nationally. The 44% 6-month readmission rate seen in the control group is more typical of this patient population.

Our study extends previous work showing the independent value of patient education, social support, and self-empowerment in improving disease management in CHF without changes in medical management.14 Additionally, we stressed early ambulation and low-intensity exercise to aid in improving outcomes. Restriction of activity levels in CHF patients may have long-term deleterious effects on muscle function and exercise tolerance.16 Exercise training improves exercise tolerance and reduces exertional symptoms, while diminishing sympathetic tone and increasing vagal tone,16–20 which have been associated with improvement in long-term outcomes and mortality.21,22

A comprehensive education program reinforced in the outpatient setting is essential for improving outcomes in patients with CHF. Patient education empowers patients to assume responsibility for disease management by increasing their knowledge base,23 promoting independent decision making, fostering adherence to treatment protocols,24 and utilizing strategies to prevent relapses.25 Lack of knowledge related to symptoms and poor compliance with treatment, specifically diet, medication use, and weight monitoring, are major contributing factors in the exacerbation of heart failure requiring admissions.26 Clinical practice guidelines for CHF published by the Agency for Health Care Policy and Research27 recommend that all heart failure patients and their families be educated about the disease, its prognosis, prescribed medications, diet, and symptom control. Patient education can significantly reduce readmission rates for patients with heart failure as a result of daily weight monitoring and prompt response to increasing symptoms.26–30 Ideally, patient education should be initiated during hospitalization, but there are many barriers to learning during hospitalization, including decreased length of stay, inadequate staffing, anxiety, weakness, fatigue, and the acute nature of the illness.

Telephone follow-up provides an efficient method for initiating and maintaining contact with patients after discharge. Telephone contact is an excellent means of allaying fear and anxiety, providing additional support, assessing needs, reinforcing information, and allowing for patient feedback, and has been found to improve disease management. Improvement in patient/family satisfaction has also been attributed to telephone follow-up. Patients who are routinely called complied more readily with the recommended guidelines and reported symptoms more promptly than those without telephone follow-up.31–34

Utilization of home care services is another effective way to decrease the use of acute care and emergency services in CHF. Regular follow-up by home care nurses who have been specially trained in CHF has been recommended as a means for improving management. These nurses should be skilled in cardiac assessment, heart failure management, and patient education.35 During each follow-up encounter, the home care nurse can assess for increasing signs and symptoms of heart failure, evaluate compliance with diet and medication, monitor weight status, and reinforce education guidelines. Skilled home care follow-up can help to reduce length of stay and decrease readmission rates by helping to prevent many potential crises.36,37

Limitations of the Study. The study was limited due to several factors. The sample size was relatively small and selection for the intervention was not performed in a prospective, blinded, randomized fashion. The nurse educator randomly screened CHF subjects from a consecutive group of patients, however, and the groups were well matched on baseline demographics. Additionally, our results are consistent with prior studies. Although our study was performed at a single center, the protocol is quite simple and could be easily applicable to other health care systems. Limited diversity related to race was another limitation, as there were few minorities in our study. Women, however, were well represented.

Our study was led by a trained cardiac nurse educator. The availability of faced by many hospitals. Thus, implementing a program without nurses with similar clinical training may trained nurses providing CHF education may be limited, especially in light of downsizing and budget restrictions result in less-than-optimal outcomes. Our study was carried out without the aid of a sophisticated patient tracking software program that would allow more detailed patient follow-up. The program was also carried out without home telemonitoring for patient vital signs and weight management, which is now widely available. Additionally, our program was intensive in nature, but brief, and the optimal duration of intervention is not known.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References

Our study highlights the role of patient education and empowerment in reducing event rates in CHF independent of medical management. The reduction in CHF readmission rates in our study was similar to more comprehensive trials including concomitant medical management. It is highly likely that our intervention led to more physician input as compared with the usual care group, but this was not assessed in our trial. Extending the results of prior trials, these results suggest that all CHF patients should be offered comprehensive education and support that begins in the hospital and continues in the outpatient setting.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Conclusions
  7. References
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