Home-Based, Low-Cost Strategies for Improving Adherence and Preventing Readmissions Among Heart Failure Patients

Patients spend far more time in the home than with their healthcare providers, making the home an ideal and perhaps essential place to improve adherence and outcomes. In this session, Kathryn Donofrio, DNP, MBA, RN, from Swedish Covenant Hospital, and Debra Moser, DNSc, MN, RN, from the University of Kentucky, discussed home-based strategies for care improvements in patients with heart failure.

Patients spend far more time in the home than with their healthcare providers, making the home an ideal and perhaps essential place to improve adherence and outcomes. Two studies presented at the American Medical Association Scientific Sessions focused on home-based strategies for care improvements in heart failure (HF) patients.

During the session “Approaches to Disease and Self-Management,” Kathryn Donofrio, DNP, MBA, RN, director of cardiovascular services, women’s health center, Swedish Covenant Hospital, discussed a telemonitoring pilot program that led to significant reductions in 30-day hospital readmission rates. The success of the program pointed to the importance of engaging patients in their own care.

Ms Donofrio noted that HF is the primary reason for hospitalization, and more than 1 in 4 of those who are hospitalized are readmitted within 30 days. The good news is, many of the readmissions are preventable, “with improved care coordination, and better symptom management and adherence to medications and diet,” she said.

The Hospital Readmissions Reduction Program, established under the Patient Protection and Affordable Care Act, requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to hospitals with a readmission performance higher than the national average for the hospital’s set of patients with HF, acute myocardial infarction, or pneumonia. Ms Donofrio said, “We wanted to find a way to address this problem in our hospital.”

The study examined the impact that a home-based monitoring program would have versus usual care (UC). Telemonitoring patients received 2 home visits by a nurse consisting of HF education and instruction on the use of home telemonitoring equipment. Over 3 months, the device transmitted vital signs, weight, and pulse oximetry daily. The patient and physician were notified of any significant changes or trends.

Researchers compared readmission rates between the telemonitoring group (n = 40) and the UC group (n = 80). Baseline characteristics were similar between groups with the exception of ejection fraction, which was lower in the intervention group compared with the UC group (38% vs 46%, respectively; P = .005).

The results showed that the all-cause, 30-day readmission rate for the group using the telemonitoring equipment was 12.5% compared with 27.5% for the UC group (P = .039). HF-related readmissions were 2.5% for the intervention group versus 10% for the UC group (P = .052).

“The program did make a difference in the bottom line,” Ms Donofrio told attendees. The cost of the program was $51,000, mostly due to purchasing equipment (approximately $400 average cost per patient). By comparison, she said that the total cost of the CMS payment decrease for excess HF readmissions at her hospital will be nearly $183,000 for 2013.

In a separate presentation, Debra Moser, DNSc, MN, RN, professor and Linda C. Gill endowed chair of nursing, University of Kentucky, discussed the results from a study designed to identify predictors that affect adherence among rural patients with HF. Ms Moser pointed out the consequences of poor adherence, especially for high-risk populations. Not following a recommended course of treatment “is a major cause of poor health outcomes and increased healthcare costs in patients with heart failure,” she said.

The study included 349 rural patients with HF (42% female; 89% white; and 56% older than 65 years). The study examined demographic and sociologic factors related to symptom management and self-care. Factors included age, gender, marital status, education level, depression score, anxiety score, and level of perceived control.

The measure for perceived control is designed to capture the degree to which an individual believes he or she has the resources required to cope with negative events.

Adherence was measured using the Heart Failure Self Care Score, a brief measure that asked patients to report their adherence to a variety of recommended behaviors (medications, diet, exercise, daily weight monitoring, and when to contact their physicians).

The study found that predictors of good adherence to self-care were: being male (P = .01); fewer symptoms of depression (P= .05); less anxiety (P = .03); and a greater level of perceived control (P = .08).

Patients are nonadherent for a variety of reasons. The data presented suggest that interventions for adherence should include an assessment of gender, and should also take into account symptoms of depression and anxiety, as well as perceived control. Ms Moser concluded by stating, “We need to reframe our view of the importance of patients feeling they have control.”