EBP Paper

Running head: IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 1

Impact of Nurse-Led Outpatient Follow-Up Care on Reducing Heart Failure Readmission Rates

Allison Blackburn, Samantha Rabuck, and Jenne Rivera

Alvernia University

IMPACT OF NURSE CARE ON HEART FAILURE READMISSION 2

Introduction

There are many areas in the healthcare field that need to be addressed to continually

improve care and, therefore, optimize the quality of care. In this case, there is an increasing

problem with heart failure patients. Each year there are at least 825,000 new patients diagnosed

with heart failure (Thomas, Hawkins, Perkins, Hamilton, & Nelson, 2015). The biggest issue is

that the rate of new incidences continues to rise. Since 2006, the number of new diagnosis has

increased from 500,000 new cases, and is classified as one of the major health problems,

especially over the age of sixty-five (Kutzleb & Reiner, 2006). The increase in diagnosed heart

failure patients poses a problem in the healthcare system in which many patients are treated,

discharged, and soon return to the hospital for the same reason. This evidence-based research

focuses on the implementation of additional interventions that can decrease the rate of

readmission and, therefore, decrease cost.

Population

The emphasis of this research focuses on a population that includes recently discharged

heart failure patients. These patients are at high risk for returning to the hospital within thirty

days. Readmission rates are becoming increasingly significant as hospitals are not reimbursed for

patient readmissions that are directly correlated to heart failure exacerbation. In hopes of

reducing readmissions, hospitals are initiating performance expectations and policies, in which

nurses take on a vital role. Optimal nursing care is necessary in delivering best practice in

healthcare, as nurses are primary advocates for the patient and provide individualized teaching.

Intervention

Many organizations agree on the importance of patient education in caring for patients

with heart failure. Continued outpatient teaching and care can significantly reduce readmission


rates as well as costs (Koelling, Johnson, Robert, Cody, & Aaronson, 2004). Outpatient care that

can benefit patient outcomes include telephone follow-ups and nurse-led group educational

sessions in combination with discharge teaching.

Studies have been conducted to demonstrate how nurse-led outpatient follow-up care can

positively affect patient health. Outpatient follow-up care includes the implementation of follow-

up calls within 48-72 hours after discharge and providing continued support beyond this time

frame (Lee & Sunhee, 2010). Nurses must be available to support patients as they transition from

the inpatient to the outpatient setting. Weekly nurse-led group educational sessions can be

another resource for patients and families to continue increasing their knowledge of heart failure.

Comparison

Under normal circumstances, this population receives discharge patient teaching about

the disease process and important self-care interventions, but the issue of readmissions continues

to exist causing continued loss of reimbursements. Healthcare goes beyond the interventions

provided within the inpatient facility. It also includes care of patients outside the hospital

settings.

Outcome

By comparing current practice to an additional intervention such as nurse-led outpatient

follow-up care, research can show if the outcome results in decreased acute care readmission

rates. Overall, there is a need for initiating new evidenced-based practice to reach a favorable

outcome.

Population, Intervention, Comparison, Outcome (PICO) Question

This evidenced-based research seeks to answer the question: In heart failure patients

recently discharged from the hospital, does additional nurse-led outpatient follow-up care,


compared to sole implementation of discharge teaching instructions by registered nurses,

decrease acute care readmission rates?

Significance

The nursing role is significant to patient education in reducing readmissions and costs.

When nurses take on their role as educators, they are able to provide individualized patient

education within and outside of the hospital. Ongoing patient education can positively impact

patient health and significantly reduce mortality when providing the necessary interventions

(Koelling et al., 2004). As educators, nurses can continue with follow-up calls and lead weekly

educational groups to provide an extra resource for patients after discharge and help them to

effectively manage necessary lifestyle changes. Weekly sessions also gives patients a place to

build a support system and promotes compliance of self-care changes. Ongoing telephone

follow-up gives patients the chance to speak one-on-one with the nurse about any concerns they

may have and specific teaching can be continually reinforced.

Effective communication in nursing is also significant to patient education as it promotes

rapport and helps to build a trusting relationship between the nurse and patient. With culturally

sensitive and thorough communication, the patient may be more receptive to self-care teaching.

In order for the nurse to provide effective teaching and improve patient outcomes, they must

have excellent communication skills and understand how to utilize them in their practice.

Current Practice

In the Progressive Care Unit at a local community hospital, current practice involves

discharge teaching specific to the patient with heart failure. Patients are given educational

booklets providing major teaching points necessary post-discharge. This booklet is named as

follows: “Caring for your Heart at Home: Guidelines for Patients with Heart Failure.” Nursing


discharge teaching involves educating the patient on the importance of taking daily weights,

monitoring sodium and fluid intake, medication compliance, and reporting of signs and

symptoms of exacerbation. If the family is available, the nurse also includes them when teaching

the patient.

Evaluation of Evidence

Thorough inpatient teaching provides a foundation for patients to make appropriate

lifestyle modifications in order to successfully manage heart failure at home. A heart failure

educational packet, such as the one provided upon discharge from one local community hospital,

outlines many pertinent points regarding self-care and management of this complex disease. In

addition to providing the heart failure educational packet, nurses are in a vital position to explain

to patients how they can best manage their heart failure at home, and provide insight into what a

heart failure diagnosis means in the context of the patient’s current lifestyle (Kuzleb & Reiner,

2006). Inpatient teaching points that the nurse must emphasize include: what a heart healthy diet

consists of, sodium restrictions that may be in place, the importance of checking food labels, the

proper technique for obtaining and recording daily weights, and the reasoning for strict

compliance with each medication (Smeltzer, Bare, Hinkle, & Cheever, 2010). According to

Albert et al. (2015), building rapport and maintaining a trusting relationship with the patient and

family promotes more successful self-care and management of heart failure. Albert et al. (2015)

and Kuzleb & Reiner (2006) both display evidence that suggests nursing advocacy and

involvement in thorough education and communication yields a positive effect on successful

management of heart failure. Excellent self-care ultimately reduces the likelihood of acute care

readmission.


Potential strategies to improve nurse-patient communication and facilitate rapport may

include active listening skills on behalf of the nurse, including a caregiver or family support

person in the teaching process, providing the patient and family with the nurse’s contact

information, and ongoing communication via telephone once the patient is discharged. Lee &

Park’s (2010) meta-analysis provides level I evidence that suggests telephone-based nurse-led

intervention significantly decreases hospital readmission rates among heart failure patients.

According to Lee & Park (2010), post-discharge telephone contact allows for continued

monitoring of patient symptoms, provides the opportunity for the nurse to reinforce patient

education, and supports open communication between the nurse and patient. Despite the home-

health focus and telemonitoring system approach to Thomason, Hawkins, Perkins, Hamilton, and

Nelson’s (2015) study, the main findings of their article correlate closely to those of both Lee &

Park (2010) and Smith (2013). Each of these studies, ranging from level I to level IV evidence,

propose similar findings in regards to the benefits of post-discharge follow-up telephone contact

in reducing acute care readmission.

To implement this intervention, the nurse is responsible for providing a post-discharge

follow-up telephone call to the patient within two to three days in order to evaluate well-being

and compliance. Each telephone call gives the nurse an opportunity to verbally assess the patient

and detect signs or symptoms of worsening condition (Lee & Park, 2010; Thomason et al., 2015;

Smith, 2013). Early recognition of symptoms allows the nurse to quickly intervene. Furthermore,

the nurse can seek to determine the reason for symptom exacerbation and provide additional

patient education accordingly. Continued telephone contact provides the opportunity for the

nurse to reinforce patient education and serve as a support person in the plan of care (Lee &

Park, 2010; Thomason et al., 2015). The patient learns how to recognize and manage symptoms


independently when the nurse continually provides patient-specific teaching based on their

assessments and the patient’s subjective symptoms. Nurses are able to hold patients accountable

for management of their heart failure and improve their ability to recognize symptoms of

exacerbation when they require that the patient provide pertinent data, such as a daily weight

(Thomason et al., 2015). Asking patients questions about their current condition facilitates

involvement in self-care, and patients may feel more accountable when they know they will need

to monitor and report data to the nurse each day. Lastly, continued telephone contact provides

patients with the opportunity to ask questions and express concerns regarding home management

of heart failure. The evidence suggests that these benefits of nurse-patient telephone contact post-

discharge result in more successful self-care and management of heart failure, which ultimately

reduces acute care readmission rates.

In addition to telephone follow-up by the nurse post-discharge, weekly nurse-led group

educational sessions are another way to reduce readmission rates for patients who have been

diagnosed with heart failure. This intervention requires nurses to conduct educational sessions at

the hospital each week to reinforce self-care and management techniques. Evidence shows that

patients are more engaged in a group setting because of increased interactions, which has

multiple benefits for patients managing a chronic illness such as heart failure (Slyer & Ferrara,

2013). Slyer and Ferrara (2013) report level I evidence based on a synthesis of randomized

controlled trials, non-randomized controlled trials, quasi-experimental trials, and qualitative

study designs. The level of evidence is a strength of this study; however, the cause of

readmission among heart failure patients attending group educational sessions was not taken into

account. Although this is a limitation for this particular study, both Slyer and Ferrara (2013) and


Koelling, Jonson, Cody, and Aaronson (2005) present evidence that supports a group educational

model in reducing acute care readmission rates in patients with heart failure.

The evidence suggests that patients who attend weekly nurse-led group educational

sessions are more consistent in following a heart failure self-care regimen (Slyer & Ferrara,

2013; Koelling et al., 2005). Increased interaction among group members and the nurse invites

patients to ask questions regarding self-care (Slyer & Ferrara, 2013). This further engages

patients in the management of their condition and promotes a better understanding of self-care

strategies. In general, additional reinforcement of educational content increases the patient’s

knowledge. This same concept applies to patients who are learning to adjust their lifestyle to

manage their heart failure at home. Slyer & Ferrara (2013) report that group visits, as compared

to one-on-one visits with a health care provider, demonstrated increased patient knowledge of

heart failure and self-care abilities. Furthermore, a group visit model has the potential to increase

quality of life. Attending educational sessions with peers who are experiencing the same

condition encourages mutual support, promotes accountability, and results in increased

compliance to a self-care regimen (Slyer & Ferrara, 2013). Peer support also fosters a sense of

belonging and empowerment which may help the patient feel more in control of their condition.

Depression often accompanies chronic health issues due to its effect on quality of life and other

factors such as financial burden. According to Slyer & Ferrara (2013), continuous support from

others who are battling the same condition may combat depression. Similar to telephone contact,

seeing a patient weekly allows the nurse to monitor for exacerbation of symptoms and intervene

as necessary. Not only do patients learn from the educational content the nurse presents, but

patients also benefit from the knowledge and experiences of others (Slyer & Ferrara, 2013).

Nurses must utilize this evidence when educating patients in order to promote a greater


understanding of heart failure and ways in which it can be managed. Techniques supported by

the latest evidence, such as post-discharge telephone contact and nurse-led group educational

sessions, have shown outcomes that include a decrease in readmission rates in heart failure

patients.

Recommendations for Nursing Practice

Based on the positive patient outcomes of telemonitoring and weekly nurse-led

educational sessions, all hospitals should begin implementing these interventions to reduce the

readmission rate of patients diagnosed with heart failure. Telemonitoring allows the nurse to

identify exacerbations of the patient’s condition and resolve the issue before the patient requires

hospitalization. Building rapport with the patient is essential for this type of intervention to be

successful. Strategies to build rapport between the nurse and patient can include active listening

and open communication. Building rapport should begin with the very first encounter between

the nurse and patient, whether this is in the hospital or beginning with the first telephone

conversation after discharge. If applicable, the family should also be involved in the patient’s

care and including them in the teaching also helps to build rapport. Nurses should also provide

the patient and family with contact information to allow them to call the nurse if they have any

questions regarding the management of their heart failure. Building rapport with a patient allows

for open communication between the nurse and patient, resulting in increased compliance and

better outcomes.

To have the most successful outcomes with telemonitoring, the nurse should inform the

patient on the information that is required during each telephone call, such as a record of daily

weights. Appropriate assessment questions should be asked so the nurse is able to determine if

the patient is being compliant with their treatment regimen. The nurse will also be able to assess


if the patient is having an exacerbation of their heart failure and can respond appropriately.

During each telephone call, the nurse should emphasize one educational point that was discussed

during the conversation to encourage the patient’s learning. Telemonitoring allows the patient to

have direct contact with the nurse and should be given the opportunity to ask any questions or

discuss any concerns that they have. With open communication between the nurse and patient

through telephone calls, the patient is able to better manage their condition, which improves their

outcomes.

Hospitals should also organize a weekly nurse-led educational session and encourage all

heart failure patients to attend. Health care providers should discuss the benefits of these

sessions, such as increased knowledge of self-care techniques and management of their heart

failure, which will improve their quality of life. Participating in these weekly educational

sessions can allow the patients to support each other and hold each other accountable for the

management of their condition. Having the continuous support from others with the same

condition can help a patient feel empowered. Peer support may encourage feelings of being in

control of their condition, and may help to combat depression that often accompanies chronic

disease. Weekly nurse-led education sessions help the patients to become more involved in the

management of their heart failure and are shown to improve patient outcomes making it

extremely beneficial for hospitals to begin implementing them.

Conclusion

Heart failure is one of the most common diagnoses for people over the age of sixty-five,

and each year there are at least 825,000 new patients diagnosed (Thomas et al., 2015). High

readmission rates are a major problem with this condition, which is why this evidence-based

research focuses on strategies to reduce readmission rates. Two interventions shown to reduce


readmission rates for heart failure patients include outpatient follow-up telemonitoring and

weekly nurse-led educational sessions. Both of these interventions promote patient education and

allow the patients to manage their condition, improve their health, and reduce the risk of being

readmitted to the hospital for an exacerbation.


References

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