Care among patient diagnosed with Heart Failure

Write a paper (1,500-2,000 words) in which you analyze and appraise “

importance of continuous care among patient diagnosed with Heart

REVIEW OF LITERATURE

Adib-Hajbaghery, M., Maghaminejad, F., & Ali, A. (2013). The Role of Continuous Care in
Reducing Readmission for Patients with Heart Failure. J Caring Sci., 2(4), 255-267.

This article explores the importance of continuous care among patient diagnosed with Heart
Failure. According to this article, approximately 20-50% of geriatric patients diagnosed with
CHF undergo readmission in 2 weeks -90 days after they have been discharged. This paper
explores the impact of post discharge care in reducing the re-hospitalization rates and in
improving patient’s quality of life. The research study is a systematic review, which was
conducted to evaluate on studies that have been conducted on CHF follow up care post discharge
or patients who had been readmitted. The studies from Google search Engine, SID and
Iranmedex databases were evaluated.

The studies evaluated were those conducted from 1995-2013. A total of 21 trials were generated,
16 of which evaluated the impact on home visits, telephone monitoring and patient education

REVIEW OF LITERATURE 2
before the discharge of patients. A quarter of the studies did not report any reduction on post
discharge re-admissions of patients diagnosed with CHF. This paper concluded that the post
discharge interventions developed by nurses can considerably reduce the rates of readmissions.
Considering the inadequacy of health care resources, using patient education combination
method is an effective strategy that can be used to reduce the readmissions incidences among the
geriatric population. This article will helps in building up my literature review by providing
useful information on the effect of patient education using teach back method among the
geriatric population diagnosed with CHF.

Black, J., Romano, P., Sadeghi, B., Auerbach, A., Ganiats, T., & Greenfield, S. et al. (2014). A
remote monitoring and telephone nurse coaching intervention to reduce readmissions
among patients with heart failure: study protocol for the Better Effectiveness After
Transition – Heart Failure (BEAT-HF) randomized controlled trial. Trials, 15(1), 124.
http://dx.doi.org/10.1186/1745-6215-15-124

CHF is a public health issue which is associated with costly hospitalization. According to
evidence based research, transitional care programs do reduce readmission rates. However, the
implementations of these transition care programs are faced by various barriers such as financial
limitation and inadequate training. The aim of these randomized controlled studies is to evaluate
on the impact of these transition care programs of the population which includes establishing
interventions such as pre-education of a patient before and after their discharge, and telephone
monitoring care as well as telephone nurse coaching. The study methodology is randomized
control study. A total of 1500 participants were used. The participants were above 50 years old

REVIEW OF LITERATURE 3
and with a history of CHF. The study population was also from diverse population background.
The study reported significant reduction on hospital readmission and increase in self
management among the geriatric population diagnosed with CHF. This paper provides rich
source of information on the best strategies that can be used to improve patient transition care
using the remote technology as possible.

Chen J, Ross JS, Carlson MD, Lin Z, Normand SL, Bernheim SM. et al. (2012). Skilled nursing
facility referral and hospital readmission rate after heart failure or myocardial infarction.
Am J Med. 125(1):100. e1–9.

There has been a substantial increase on the number of hospital readmissions of patients
diagnosed with CHF. There have been a considerable number of state-level variations in the
discharge of skilled nursing facilities. However, there is limited information on hospital level
variation of SNF rates and its association with increased re-admission rates. This quantitative
research studies was conducted by evaluating the data obtained from fee charges of Medicare
patients who had a principal diagnosis of CHF. The study indicated that shortage of skilled
nurses resulted to an increase in readmission rates. However, the article did not explain on the
causes of readmission rates.

Dominque, FBI., Aliti, G., Dominguez, D., Rabelo, E., & Clausell, N. (2011). Education and
telephone monitoring by nurses of patients with heart failure: randomized clinical trial.
Arq Bras Cardiol., 9(3), 233-239.

REVIEW OF LITERATURE 4
Studies on nursing interventions in patients diagnosed with CHF reports reduced morbidity and
mortality rates. However, there is limited information on intra-hospital education and telephone
coaching. This comparative study compared two groups of patients hospitalized with CHF. The
intervention group received patient education during hospitalization, which was followed by
telephone monitoring and coaching after discharge. The control group only received training
during hospitalizations. The patient evaluated the following outcomes including self care
knowledge, the levels of CHF, re-admissions rates and the number of emergency visits. The
study findings reported a 29% decrease in number of readmission among the intervention group.
This indicated that in-hospital educational nursing intervention benefited the CHF patients by
making them understand their disease and effective self management care.

Feltner, C., Jones, C., Cené, C., Zheng, Z., Sueta, C., & Coker-Schwimmer, E. et al. (2014).
Transitional Care Interventions to Prevent Readmissions for Persons With Heart Failure.
Annals Of Internal Medicine, 160(11), 774. http://dx.doi.org/10.7326/m14-0083

Approximately 25% of the geriatric populations hospitalized with CHF are hospitalized within
the first days after discharge. The aim of this study is to assess the comparative effectiveness and
challenges of transitional care in the reduction of readmission rates as well as the mortality rates.
The paper conducted a systematic review from the CINAHL, MEDLINE, Cochrane library and
WHO registry. A total of 47 studies were identified. Most of the studies focused on geriatric
population. Some of the studies reported a 30 day readmission rates. About 65% of all the studies
indicated that integration of multidisciplinary programs such as home visiting programs
reduced the re-admission rated considerably. The paper recommended that the use of structured
telephone support (SOE) and home visiting programs should be integrated in all clinics and by
all providers who are seeking to implement the transitional care. This article is important for this

REVIEW OF LITERATURE 5
capstone project as it will facilitate in the identification of programs that aid in the reduction of
the readmission rates.

Gruneir A, Dhalla IA, van Walraven C, Fischer HD, Camacho X, Rochon PA. et al. (2011).
Unplanned readmissions after hospital discharge among patients identified as being at
high risk for readmission using a validated predictive algorithm. Open
Med.;5(2):e104–11

The unplanned hospital readmissions are common among the geriatric population and are very
expensive. These readmission rates are preventable if the appropriate strategies of patient
education and improvement of self management programs are integrated in the clinics. The aim
of this study is to identify geriatric patients at risk of readmission using an alogarithm (LACE
index). This aims at evaluating of the index is effective in identifying patients who are at high
risk of getting readmissions and to identify the factors that puts the patient at risk, and ways to
address these challenges. The study concluded that the use of LACE index score 10 is effective
in identifying patients who are at high risk, and those who can benefit to maximum after post
discharge. Therefore, this is a useful tool that can be used by the healthcare providers to identify
patients who would need the integration of the post-discharge interventions.

Hasan O, Meltzer DO, Shaykevich SA, Bell CM, Kaboli PJ, Auerbach AD. et al. (2010).
Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med.
;25(3):211–9.

The study conducted to evaluate the effectiveness of training the CHF patient’s family members
so that they can support and provide patient home care in order to improve patient’s quality of
life and to reduce the readmission rates of patients diagnosed with CHF. This single blinded

REVIEW OF LITERATURE 6
randomized control study enrolled participants through random sampling. The participants were
divided into two groups, the control group and the intervention group. The intervention group
had training during and after hospitalization. The study findings indicate that the mean score of
patient’s quality of life reduced in the control group as compared with the intervention at a
period of six months. The study concluded that nursing follow up care of CHF geriatric patients
improved their quality of life.

Hasanpour-Dehkordi, A., Khaledi-Far, A., Khaledi-Far, B., & Salehi-Tali, S. (2016). The effect
of family training and support on the quality of life and cost of hospital readmissions in
congestive heart failure patients in Iran. Applied Nursing Research, 31, 165-169.

This paper explores the early indicators patient readmission by using a complex prediction
model. The study design is prospective observation of the population, which involved 10, 496
participants. The study evaluated the number of readmission after 30 days, and grouped the
factors into four categories including the health condition, social support, health utilization and
socio-demographic factors. After performing a regression study, seven main factors were
identified including the patient insurance status, regular physicians and the patient’s marital
status. The study indicated that the nurses can utilize the prediction model effectively to identify
risk factors for readmission, and use the findings to develop an education plan that targets the
patient’s individual needs and challenges. This will help establish the efficient interventions that
will help reduce the readmission rates.

REVIEW OF LITERATURE 7
Inglis, S., Clark, R., Dierckx, R., Prieto-Merino, D., & Cleland, J. (2015). Structured telephone
support or non-invasive telemonitoring for patients with heart failure. Cochrane
Database Of Systematic Reviews.

Specialized management of CHF involves the improvement of care and clinical outcomes as well
as healthcare utilization. This paper reviews the effect of structured telephone support in
combination of non invasive home telemonitoring on CHF patients care and in comparison of the
usual standard care. The study reported a 55. 1% of the patients under the specialized
management improved their medication adherence. This reduced the patient’s risk of all because
mortality as well as the heart related disorders. The interventions indicated significant
improvements on the patient’s quality of life as well as the heart failure knowledge as well as
self care behavior.

Inglis, S., Clark, R., McAlister, F., Stewart, S., & Cleland, J. (2011). Which components of heart
failure programmes are effective? A systematic review and meta-analysis of the
outcomes of structured telephone support or telemonitoring as the primary component of
chronic heart failure management in 8323 patients: Abridged Coc. European Journal Of
Heart Failure, 13(9), 1028-1040.

Several clinical studies indicates that use of structured telephone support (STS) and
telemonitoring have high potential of helping the nursed to deliver specialized management to
patients diagnosed with CHF. However, the efficacy of telemonitoring and STS has not been
established. This meta-analysis paper evaluated the existing the randomized control trails (RCTs)
by comparing the TM and STS interventions to usual care interventions. The study findings
found that the interventions improved the patient’s quality of life, and reduced their costs

REVIEW OF LITERATURE 8
significantly. The study concluded that key strategies in reduction of patient readmission rates is
by making improvements on patient self care, patient knowledge and improve patient
functional class.

Kitsiou, S., Paré, G., & Jaana, M. (2015). Effects of Home Telemonitoring Interventions on
Patients With Chronic Heart Failure: An Overview of Systematic Reviews. J Med

The article explores the impact of post discharge patient education care using telemonitoring and
coaching of patients diagnosed with CHF. This systematic review conducted a comprehensive
literature search where a total of 15 reviews were published. The studies indicated a 1.4-6.5%
risk reduction of all causing mortality and readmission rates. The study concluded that future
studies should explore the home monitoring to identify more optimal strategies that it confers
effective self management strategies.Navidian, A., Yaghoubinia, F., Ganjali, A., & Khoshsimaee, S. (2015). The Effect of Self-Care
Education on the Awareness, Attitude, and Adherence to Self-Care Behaviors in
Hospitalized Patients Due to Heart Failure with and without Depression. PLOS ONE,

The exacerbation of CHF is influenced by factors such as the psychological factors and other
health disorders associated with old age. This paper evaluates the impact of self care education
on patient’s adherence, attitude and awareness of CHF patients who are hospitalized. The study
findings found those intervention groups have improved scores on patient attitude, awareness
and adherence as compared to control groups.

REVIEW OF LITERATURE 9
Pandor, A., Thokala, P., Gomersall, T., Baalbaki, H., Stevens, J., & Wang, J. et al. (2013). Home
telemonitoring or structured telephone support programmes after recent discharge in
patients with heart failure: systematic review and economic evaluation. Health Technol

The readmission rates for CHF patients are common among the geriatric population. Research
indicates that the integration of remote monitoring and patient education have a potential to
deliver effective and specialized care, one that will meet the growing demands for the CHF
needs for the geriatric population. Some of the challenges identifies by this study is that there is
no a care package such as protocols on communication, staff visits or other resources. This
indicated that there are still uncertainties about the effectives of Home monitoring in terms of
management of CHF patients. However, the study generalized that where standard care is less
good, then, home monitoring strategy should be used.

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “Teach-Back”
Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart
Failure Patients?. The Journal Of Cardiovascular Nursing, 28(2), 137-146.

CHF is a chronic disease that affects approximately 5.8 million people in the USA. In addition, a
further 670,000 are diagnosed with CHF annually, The large fraction of the people diagnosed
with CHF are geriatric population. The average readmission days are within 30 days after
hospital discharge. Despite the guidelines established on the importance patient education to
avoid readmissions, the most effective strategy of education is still unknown. The aim of the
paper is to explore if the teach back method of patient education aids in reduction of readmission

REVIEW OF LITERATURE 10
rates. This prospective cohort study found that teach back method of education reduced
readmission rates by 8.4 %. The study concluded that the teach back method is an effective
teaching method as it helps the patients retain the information for significantly longer time than
patients who had been taught using briefer teaching.

Vedel, I. & Khanassov, V. (2015). Transitional Care for Patients With Congestive Heart Failure:
A Systematic Review and Meta-Analysis. The Annals Of Family Medicine, 13(6), 562-

The paper is a meta-analysis paper conducted to determine the effect of transitional care
interventions on the patients diagnosed with CHF. A systematic review was conducted on the
following databases including the Medline, EMBASE, Psychinfo and Cochrane. A total of 41
randomized control studies were identified, The study indicated that integration of Transitional
care reduced the readmission rayed by 8-29%. The paper concludes that high intensive training
which involves the combination of telephone coaching, telephone follow up and clinical visits
reduced readmission risk effectively. Therefore, it is highly recommended that that the
healthcare providers should integrate these interventions in their healthcare facility.

REVIEW OF LITERATURE 11
References

Adib-Hajbaghery, M., Maghaminejad, F., & Ali, A. (2013). The Role of Continuous Care in
Reducing Readmission for Patients with Heart Failure. J Caring Sci., 2(4),

Black, J., Romano, P., Sadeghi, B., Auerbach, A., Ganiats, T., & Greenfield, S. et al. (2014). A
remote monitoring and telephone nurse coaching intervention to reduce readmissions
among patients with heart failure: study protocol for the Better Effectiveness After
Transition – Heart Failure (BEAT-HF) randomized controlled trial. Trials, 15(1), 124.

Chen J, Ross JS, Carlson MD, Lin Z, Normand SL, Bernheim SM. et al.(2012). Skilled nursing
facility referral and hospital readmission rate after heart failure or myocardial infarction.
Am J Med. 125(1):100. e1–9.

Dominque, FBI., Aliti, G., Dominguez, D., Rabelo, E., & Clausell, N. (2011). Education and
telephone monitoring by nurses of patients with heart failure: randomized clinical trial.
Arq Bras Cardiol., 9(3), 233-239.

Feltner, C., Jones, C., Cené, C., Zheng, Z., Sueta, C., & Coker-Schwimmer, E. et al. (2014).
Transitional Care Interventions to Prevent Readmissions for Persons With Heart Failure.
Annals Of Internal Medicine, 160(11), 774.

REVIEW OF LITERATURE 12
Gruneir A, Dhalla IA, van Walraven C, Fischer HD, Camacho X, Rochon PA. et al. (2011).
Unplanned readmissions after hospital discharge among patients identified as being at
high risk for readmission using a validated predictive algorithm. Open Med.
5(2):e104–11

Hasan O, Meltzer DO, Shaykevich SA, Bell CM, Kaboli PJ, Auerbach AD. et al. (2010).
Hospital readmission in general medicine patients: a prediction model. J Gen Intern Med.
25(3):211–9.

Hasanpour-Dehkordi, A., Khaledi-Far, A., Khaledi-Far, B., & Salehi-Tali, S. (2016). The effect
of family training and support on the quality of life and cost of hospital readmissions in
congestive heart failure patients in Iran. Applied Nursing Research, 31, 165-169.

Inglis, S., Clark, R., Dierckx, R., Prieto-Merino, D., & Cleland, J. (2015). Structured telephone
support or non-invasive telemonitoring for patients with heart failure. Cochrane
Database Of Systematic Reviews.

Inglis, S., Clark, R., McAlister, F., Stewart, S., & Cleland, J. (2011). Which components of heart
failure programmes are effective? A systematic review and meta-analysis of the
outcomes of structured telephone support or telemonitoring as the primary component of
chronic heart failure management in 8323 patients: Abridged Coc. European Journal Of
Heart Failure, 13(9), 1028-1040.

REVIEW OF LITERATURE 13
Kitsiou, S., Paré, G., & Jaana, M. (2015). Effects of Home Telemonitoring Interventions on
Patients With Chronic Heart Failure: An Overview of Systematic Reviews. J Med
Internet Res, 17(3), e63.

Navidian, A., Yaghoubinia, F., Ganjali, A., & Khoshsimaee, S. (2015). The Effect of Self-Care
Education on the Awareness, Attitude, and Adherence to Self-Care Behaviors in
Hospitalized Patients Due to Heart Failure with and without Depression. PLOS ONE,
10(6), e0130973.

Pandor, A., Thokala, P., Gomersall, T., Baalbaki, H., Stevens, J., & Wang, J. et al. (2013). Home
telemonitoring or structured telephone support programmes after recent discharge in
patients with heart failure: systematic review and economic evaluation. Health Technol
Assess

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “Teach-Back”
Associated With Knowledge Retention and Hospital Readmission in Hospitalized Heart
Failure Patients?. The Journal Of Cardiovascular Nursing,

Vedel, I. & Khanassov, V. (2015). Transitional Care for Patients With Congestive Heart Failure:
A Systematic Review and Meta-Analysis. The Annals Of Family Medicine,

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