Bridging the gap between hospital and home: A new model of care for reducing readmission rates in chronic heart failure

Journal of Cardiovascular Nursing

Volumn 26, Issue 5, 2011, Pages 368-376

  Manning, Shannon ^a,b,c  

^a PACIFIC LUTHERAN UNIVERSITY   (United States)

^b Ambulatory Care Center   (United States)

^c Auburn Family Medical Center Inc   (Australia)

Author keywords

heart failure; nurse educator; readmissions; risk assessment tool

Indexed keywords

ARTICLE; CHRONIC DISEASE; HEART FAILURE; HOSPITAL READMISSION; HUMAN; NURSING; PATIENT EDUCATION; RETROSPECTIVE STUDY; STATISTICS; THEORETICAL MODEL;

CHRONIC DISEASE; HEART FAILURE; HUMANS; MODELS, THEORETICAL; PATIENT EDUCATION AS TOPIC; PATIENT READMISSION; RETROSPECTIVE STUDIES;

EID: 80052275758     PISSN: 08894655     EISSN: 15505049     Source Type: Journal    
DOI: 10.1097/JCN.0b013e318202b15c     Document Type: Article

References (59)

1. American Heart Association. Heart Disease and Stroke StatisticsV2010 Update. Dallas, TX: American Heart Association; 2010.
2. Kozak LJ, DeFrances CJ, Hall MJ. National hospital discharge survey: 2004 annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat. 2006;13(162).
3. Lee WC, Chavez YE, Baker T, et al. Economic burden of heart failure: a summary of recent literature. Heart Lung. 2004;33(6):362-371. (Pubitemid 39592989)
4. O'Connell JB. The economic burden of heart failure. Clin Cardiol. 2000;23(3S):III6-III10. (Pubitemid 30124119)
5. Fang J, Mensah GA, Crost JB, et al. Heart failure-related hospitalizations in US, 1979 to 2004. J Am Coll Cardiol. 2008;52(6):428-434. (Pubitemid 352040814)
6. Albert NM, Fonarow GC, Abraham WT, et al. Predictors of delivery of hospital-based heart failure patient education: a report from OPTIMIZE-HF. J Cardiac Fail. 2007;13(3): 189-197.
7. Braunstein JB, Anderson GF, Gerstenblith G, et al. Noncardiac comorbidity increases preventable hospitalizations and mortality among Medicare beneficiaries with chronic heart failure. J Am Coll Cardiol. 2003;42(7):1226-1233. (Pubitemid 37188347)
8. Jessup M, Abraham WT, Casey DE, et al. 2009 Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016.
9. Rutledge DN, Donaldson NE, Pravikoff DS. Patient education in disease and symptom management: congestive heart failure. Online J Clin Innov. 2001;4(2):1-52.
10. Wu JR,Moser DK, Chung ML, Lennie TA. Predictors of medication adherence using a multidimensional adherence model in patients with heart failure. J Card Fail. 2008;14(7):603-709.
11. Joint Commission on Accreditation of Healthcare Organizations. Specifications Manual for National Hospital Quality Measures. Washington DC: Joint Commission on Accreditation of Healthcare Organizations. http://www.jointcommission. org/PerformanceMeasurement/PerformanceMeasurement/ Current+NHQM+Manual.htm. Accessed April, 2010.
12. Ilksoy N,MooreRH, Easley K, Jacobson TA. Quality of care in African-American patients admitted for congestive heart failure at a university teaching hospital. Am J Cardiol. 2006; 97(5):690-693. (Pubitemid 43255041)
13. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American heart association. Circulation. 2009;120(12):1141-1163.
14. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
15. Ross JS, Chen J, Lin A, et al. Recent national trends in readmission rates after heart failure hospitalization. Circulation. 2010;3(1):97-103.
16. Centers for Medicare & Medicaid Services Hospital Pay-for-Performance Workgroup. US Department of Health and Human ServicesMedicare Hospital Value-Based Purchasing Plan Development, Issues Paper, I Public Listening Session, January 17, 2007. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/AcuteInpatientPPS/Downloads/Hospital-VBP-Plan-Issues- Paper.pdf. Accessed April, 2010.
17. Vansuch M, Naessens JM, Stroebel RJ, Huddlestone JM, WilliamsAR. Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Qual Safe Health Care. 2006;15(6):414-417. (Pubitemid 46025152)
18. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111(1):179-185. (Pubitemid 40139729)
19. Krumholz HM, Amatruda J, Smith GL, et al. Randomized trail of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol. 2002;39(2):83-89. (Pubitemid 34059865)
20. Debusk RF, Miller NH, Parker KM, Bandura A, Kraemer HC, Cher DJ. Improving patient care: care management for low-risk patients with heart failure; a randomized control trial. Ann Inter Med. 2004;141(8):606-613. (Pubitemid 39390538)
21. Yu DSF, Thompson DR, Lee DTF. Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. Eur Heart J. 2006;27(5):596-612.
22. Linden L, English K. Adjusting the cost-quality equation: utilizing work sampling and time study data to redesign clinical practice. J Nurs Care Qual. 1994;8(3):34-42.
23. Urden L, Roode J. Work sampling: a decision-making tool for determining resources and work redesign.J Nurs Admin. 1997;27(9):34-41. (Pubitemid 27391604)
24. Evangelista LS, Rasmusson KD, Laramee AS, et al. Health literacy and the patient with heart failureVimplications for patient care and research: a consensus statement of the Heart Failure Society of America. J Card Fail. 2010;16(1): 9-16.
25. Anderson MA, Levsen J, Dusio ME, et al. Evidence-based factors in readmission of patients with heart failure. J Nurs Care Qual. 2006;21(2):160-167. (Pubitemid 44510391)
26. Annema C, Luttik ML, Jaarsma T. Reasons for readmission in heart failure: perspectives of patients, caregivers, cardiologists and heart failure nurses. Heart Lung. 2009;38(5): 427-434.
27. Howie-Esquivel J, Dracup K. Effect of gender, ethnicity, pulmonary disease and symptom stability on rehospitalization in patients with heart failure. Am J Cardiol. 2007;100(4): 1138-1144.
28. Johansson P, Dahlstrom U, Brostrom A. Consequences and predictors of depression in patients with chronic heart failure: implications for nursing care and future research. Prog Cardiovasc Nurs. 2006;21(14):202-211.
29. Lee CS, Riegel B, Driscoll A, et al. Gender differences in heart failure self-care: a multinational cross-sectional study. Int J Nurs Stud. 2009;46(11):1485-1495.
30. Feola M, Aspromonte N, Milani L, et al. Plasma brain natriuretic peptide predicts short-term clinical outcome in heart failure patients with restrictive filling patters. J Card Fail. 2008;14(5):420-425. (Pubitemid 351749837)
31. Feola M, Aspromonte N, Canali C, et al. Prognostic value of plasma brain natriuretic peptide, urea nitrogen and creatinine in outpatients 970 years of age with heart failure. Am J Cardiol. 2005;96(5):705-709. (Pubitemid 41207318)
32. Filippatos G, Rossi J, Lloyd-Jones DM, et al. Prognostic value of blood urea nitrogen in patients hospitalized with worsening heart failure: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist on Chronic Heart Failure (ACTIV in CHF) study. J Card Fail. 2007;13(5):360-364. (Pubitemid 46977793)
33. Felker GM, Leimberger JD, Calliff RM, et al. Risk stratification after hospitalization for decompensated heart failure. J Card Fail. 2004;10(6):460-466.
34. AschSM, Kerr EA, Keesey J, et al.Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006; 354(11):1147-1156.
35. Kossovsky MP, Sarasin FP, Louis-Simonet M, et al. Age and quality of in-hospital care of patients with heart failure. Eur J Public Health. 2004;14(2):123-127. (Pubitemid 38821571)
36. Macabasco-O'Connell A, Crawford MH, Stotts N, Stewart A, Froelicher, ES. Gender and racial differences in psychosocial factors of low-income patients with heart failure. Heart Lung. 2010;39(1):2-11.
37. Pressler SJ. Cognitive functioning and chronic heart failure a review of the literature (2002-July 2007). J Cardiovasc Nurs. 2008;23(3):239-249.
38. Luttik ML, Jaarsma T, Moser D, Sanderman R, Van Velduisen DJ. The importance and impact of social support on outcomes in patients with heart failure. J Cardiovasc Nurs. 2005;20(3):162-169.
39. McEnteeML, Cuomo LR, DennisonCR. Patient-, provider-, and system-level barriers to heart failure care. J Cardiovasc Nurs. 2009;24(4):290-298.
40. Rodriguez-Artalejo F, Guallar-Castillon P, Herrera MC, et al. Social network as a predictor of hospital readmission and mortality among older patients with heart failure. J Card Fail. 2006;12(8):621-627. (Pubitemid 44512146)
41. Jenner RC, Strodl ES, Schweitzer RD. Anger and depression predict hospital use among chronic heart failure patients. Aust Health Rev. 2009;33(4):541-548.
42. Sayers SL, Hanrahan N, Kutney A, Clarke SP, Brandali FR, Riegel B. Psychiatric comorbidity and greater hospitalization risk, longer length of stay and higher hospitalization costs in older adults with heart failure. J Am Geriatr Soc. 2007; 55(10):1585-1591. (Pubitemid 47508502)
43. Sarkar U, Ali S, Whooley MA. Self-efficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary heart disease: findings fromthe heart and soul study. Health Psychol. 2009;28(2):166-173.
44. ChungML, Lennie TA, Riegel B,Wu JR, Dekker RL,Moser DK.Marital status as an independent predictor of event-free survival of patients with heart failure.Am J Crit Care. 2009; 18(6):562-570.
45. Roe-Prior P. Sociodemographic variables predicting poor post-discharge outcomes for hospitalized elders with heart failure. Medsurg Nursing. 2007;16(5):317-321.
46. McAlister FA, Stewart S, Ferrua S, McMurray JJJV. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials.J Am Coll Cardiol. 2004;44(4):810-819. (Pubitemid 39099578)
47. Gonseth J, Guallar-Castillon P, Banegas J, Rodriguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta analysis of published reports. Eur Heart J. 2004;25(18):1570-1595. (Pubitemid 39209278)
48. Hollad R, Battersby J, Harvey I, Lenaghan E, Smith J,Hay L. Systematic review of multidisciplinary interventions in heart failure. Heart. 2005;91(7):899-906. (Pubitemid 40874078)
49. Pattenden J, Coulton S, Spilsbury K, et al. The Development and Impact of the British Heart Foundation and Big Lottery Fund Heart Failure Specialist Nurse Services in England Final Report. London: British Heart Foundation; 2008. http://www2.biglotteryfund.org.uk/er-eval-develop-impact-bhf-big-nurse-services- final-rep.pdf. Accessed April, 2010.
50. Dowding D, Spilsbury K, Thompson C, Brownlow R, Pattenden J. The decision making of heart failure specialist nurses in clinical practice. J Clin Nurs. 2009;18(9):1313-1324.
51. Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol. 1997;30(2):518-526. (Pubitemid 27339334)
52. Bello D, Shah NB, Edep ME, Tateo IM, Massie BM. Selfreported differences between cardiologists and heart failure specialists in the management of chronic heart failure. Am Heart J. 1999;138(1):100-107. (Pubitemid 29331128)
53. Anasari M, Shilpak MG, Heindenreich PA, et al. Improving guidelines adherence: a randomized trial evaluating strategies to increase "-blocker use in heart failure. Circulation. 2003;107(22):2799-2804.
54. Rasmussen KD, Brush SJ, Hall JA, Vesty JC, Kfoury AG, Renlund DG. Bridging the resource gap in heart failure expertise and management: the underacknowledged role of nurse specialists. J Am Coll Cardiol. 2005;46(10):1961-1962. (Pubitemid 41579824)
55. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684. (Pubitemid 38596483)
56. Riegel B, Carlson B, Glaser D. Hoagland P. Which patients with heart failure respond best to multidisciplinary disease management? J Card Fail. 2000;6:290-299. (Pubitemid 32051876)
57. Slater MR, Phillips DM, Woodard EK. Cost-effective care a phone call away: a nurse-managed telephonic program for patients with chronic heart failure. Nurs Econ. 2008;26(1): 41-44.
58. Di Salvo TG, Stevenson LW. Interdisciplinary team-based management of heart failure. Dis Manage Health Outcomes. 2003;11(2):87-94. (Pubitemid 36246300)
59. Seow H, Phillips CO, RichMW, Spertus JA, KrumholzHM, Lynn J. Isolation of health services research from practice to policy: the example of chronic heart failure management. J Am Geriatr Soc. 2006;54:535-540. (Pubitemid 43327170)