- Top of page
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.
- Top of page
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.