Evaluation of Transitional Care through Home Care Services for Heart Failure Patients to Decrease 30-day Readmissions

Purpose:
Evaluate if the use of transitional care services through home care services reduced hospital readmissions within 30-days as compared to usual self-care at home for HF patients. Assess the strengths and weaknesses of the key processes under IHI:Creating an Ideal Transition Home for Patients with HF

Background/Significance:
The national rate of hospital readmission within 30-days for heart failure patients is 24.7% and 50% 6-months post discharge. Hospitalization for heart failure patients is an independent risk factor for shortening a patient's survival. Multidisciplinary approaches and disease management strategies are recognized as having a significant role in decreasing hospital readmissions. The Patient and Affordable Care Act of 2010 proposes financial incentives to reduce Medicare 30-day readmissions.

Methods:
Retrospective chart reviews of hospital and home care records of Medicare patients discharged (N=76) and those readmitted from a large northern NJ hospital from Jan-April 2010 with a primary diagnosis of HF. The dependent variable was 30-day readmission. Independent variables identified were patient demographics, clinical variables, and complete discharge instructions. The IHI four key processes of admission assessment for discharge needs, teaching learning processes and handoffs, through to post acute follow up plans were evaluated for strengths and weaknesses. SPSS version 17 was utilized for statistical analysis using t-tests, chi-square, and binary logistic regression.

Results:
No statistical significant difference in hospital readmissions between the patients discharged to self-care (n=7 of 40, 17.5%) and home care services (n=11 of 36, 30.5%), p= 0.181. The patients in home care were a statistically older, sicker population with more functional limitations.There also was a significant increase in readmissions for patients who had had a longer index admission length of stay (LOS)with a mean LOS of 5.5 days(SD=2.6),compared to the non-readmitted patients mean LOS of 3.5 days(SD=2.2,at p= 0.002.Only 19% of discharge diets had specific sodium restrictions vs. a "cardiac diet." In the hospital, teach back was not routinely utilized for evaluating learning.

Conclusions and Implications for Practice:
Opportunities for improving teaching/learning processes for all HF patients/families were identified. Nurse evaluation and modeling of self-care behaviors are essential to improve hospital teaching-learning processes and plan for discharge needs with transitional nursing services.