Heart disease is one of the most prevalent chronic diseases in this country.1 Among the medical conditions with the highest rates of rehospitalization within 30 days of discharge, heart failure leads the way.2 Approximately 5.7 million people in the United States have been diagnosed with heart failure.1 The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines has issued valuable guidance for heart failure management.3
The Patient Protection and Affordable Care Act seeks to, among other things, reduce healthcare costs by improving the management of chronic disease.4 Chronic diseases are a leading cause of disability and death in the United States.5 Effective post-discharge follow-up care can reduce readmission rates for chronic diseases such as heart disease.6 Specifically, research shows that telehealth services can reduce healthcare costs, including those generated by unplanned hospital admissions and emergency department visits.7
Telehealth is one innovation that can decrease hospitalizations.8 The ability to frequently monitor vital signs and symptoms of chronic diseases via telehealth equipment, instead of only during periodic office visits or home health visits, allows for early detection of the worsening of chronic diseases, paving the way for earlier interventions.9 Armed with guidelines for heart failure management that outline specific actions based on evidence-base practice research,3 nurse practitioners, physician assistants and nurses can play a key role in overall management of this disease.
According to the ACCF/AHA heart failure guidelines, key provider activities prior to discharge include: medication reconciliation, initiation of oral therapies such as angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers and beta-blocker therapy, and comprehensive written discharge instructions. Guidelines further emphasize that post-discharge systems of care, such as telecommunication, should be used to facilitate the transition to effective outpatient care.3
We performed a literature search on the subject of telehealth, using the search terms "heart failure," "prevention of readmission," "telehealth," "telemonitoring," "telecommunications," "telehomecare" and "home monitoring." We searched for studies published between 2004 and 2012 and included the medical databases CINAHL, Cochrane Library and Medline. Consistently, search results yielded studies supporting the development and implementation of post-acute care chronic disease management using telehealth. Evidence-based practice studies such as systematic reviews of randomized, controlled trials (RCTs), single RCTs, single correlational/observational studies and a single nonrandomized trial were found.
In general, this research indicates a trend in care delivery outcomes improvement in which the delivery of post-acute care disease management interventions and patient teaching make a difference. For example, a Level 1a systematic review of RCTs by Clark et al, published in 2011, found that remote monitoring programs reduced the rate of readmission by 21% for patients with heart failure.10 Of the six trials reviewed, three reported significant quality-of -life benefits10-12 and four reported cost reductions.10,11,13,14 The Level 1a systematic review of RCTs by Inglis et al, published in 2010, determined that telemonitoring reduced all-cause mortality when structured telephone support and telemonitoring were provided.11 In another telehealth study, significantly more visits to the emergency department were noted in a control group than in the telehealth intervention group,15 and another study found that for patients with heart failure on a 60-day telehealth program, readmissions were 13.3% less than for those receiving routine home care.16
Program for Heart Failure Management
Texas Health Harris Methodist Hospital in Fort Worth, Texas, has been steadily working to identify needs, develop ideas and research and implement programs to combat hospital readmissions. Of the more than 700 beds at this hospital, 100 are dedicated to patients with heart disease. The institution recognized a serious need and in 2007 developed a heart failure (HF) readmission task force to develop recommendations to help meet the needs of patients diagnosed with heart failure.
The task force was comprised of physicians on the medical staff, nurses, educators, managers, directors, and administrators. As areas of concern were identified, ideas were discussed and debated, which led to evidenced-based research policies and programs. The new policies and programs implemented by the HF task force included:
-medication reconciliation and education provided by pharmacists at the time of admission
-continuation and reinforcement of medication education by nursing staff throughout hospitalization and at the time of discharge
-HF treatment team rounding (pharmacist, unit manager, cardiovascular center director, social worker, case manager, and designated hospitalist)
-HF classes taught by designated cardiovascular education specialists and cardiovascular clinical nurse specialists
-follow-up telephone calls by a designated cardiovascular nurse after discharge.
The most recent effort to assist in decreasing rehospitalization of HF patients was the opening of an outpatient clinic. The clinic opened in June 2012 and has been directed by a nurse practitioner. The initial statistics for the clinic are promising. Of the 190 appointments scheduled at the time of discharge from the acute care setting, 136 patients kept their appointments (72%). Equally as impressive was the associated decrease in HF readmission rates. In May 2012, the readmission rate was 19.3%; in June, July and August, rates were 10.7%, 12.5% and 12.0%.
Today, the nurse practitioner-based clinic, which remains a vital part of the organization's approach to heart failure management, continues with positive outcomes. Of 522 discharged patients, 339 kept their clinic appointments (65%). In terms of 2013 HF readmission rates, from October 2012 through March 2013, the hospital recorded a 30-day monthly readmission rate ranging from a 8.9% to 17.4%. These rates are still substantially below the 2004 national average of 19.6%.1
Teaching post-acute care to acute care professionals requires three main components. The first is teaching an alternative method of assessing patients, via telehealth equipment instead of in person.17 The second is developing excellent communications skills, which strengthen patient rapport and serves as the main avenue for data collection. The final component is teaching protocols for when to intervene with referrals, education, prescriptions or other treatment.
Post-acute providers must have excellent assessment skills to detect worsening of HF, thus leading to early intervention. Assessing patients via telehealth monitoring can be challenging because it is different from how data is traditionally gathered and interpreted. This type of monitoring requires both subjective and objective data.18 A clinician with experience in telehealth requires minimal technical assistance or support to accomplish subjective and objective patient monitoring.19
In telehealth, the provider's ability to communicate effectively with the patient can ultimately affect the health and life of the patient being served; excellent communication skills are of utmost importance.17 Telehealth professionals must develop appropriate attitude, voice quality, motivational interviewing and communication etiquette.17
Attitude and etiquette lay the foundation for how the provider is perceived by the patient. Conveying a caring attitude is essential in telehealth because the patient will immediately judge whether or not this trait is present and whether he or she can trust the provider to meet personal needs.17
One aspect affecting a patient's perception of attitude is the quality of the provider's voice, particularly tone, volume, clarity and speed. Etiquette involves the prompt answering of calls, questions and concerns.17 Since the patient may not be able to see the provider or his/her expressions and gestures, the provider's voice quality, as well as attitude and etiquette, influence the provider-patient relationship.17
Communication techniques necessary for effective telecommunication are listening skills, interviewing techniques, effective closure of the encounter, and as noted, motivational interviewing.17 Motivational interviewing is a key technique to master in dealing with patients who have chronic diseases. HF can be difficult to manage, and most patients require lifestyle changes. Adherence to medication regimens, along with smoking cessation, sodium and fluid intake restriction, weight management, dietary and alcohol limits, exercise and stress reduction, are critical lifestyle changes that require support and close follow-up.20 Simply instructing a patient to change problematic behaviors is often ineffective, and patient adherence to self-care regimens is usually less than optimal.17 To enhance patient adherence, motivational interviewing can build a collaborative and supportive relationship that empowers the patient's conviction, confidence and readiness to change.21
The last component of a transition to post-acute care is educating providers about the appropriate care protocols to follow with the information and data they collect from patients. The protocol may necessitate a referral, scheduling of an appointment, more education, or a specific intervention such as a change in medication. Symptoms such as dyspnea, orthopnea, peripheral edema, fatigue or an increase in weight suggest a worsening of HF.22 These symptoms require prompt attention and accurate intervention.22
Conclusions and Recommendations
Heart failure is a serious medical condition affecting more than 5 million people in the United States.1 It is a chronic illness that requires a comprehensive approach to management. Our discussion here outlines how one acute care facility created a task force to develop protocols and programs that have positively affected readmission rates and improved patient care and satisfaction.
1. CDC. Chronic disease prevention and health promotion. http://www.cdc.gov/chronicdisease/overview/index.htm
2. Jencks SF, et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.
3. Jessup M, 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.
4. USDHHS. What's changing and when. http://www.healthcare.gov/law/timeline
5. World Health Organization. Health topics: Chronic diseases. www.who.int/topics/chronic_diseases/en/
6. Center for Healthcare Quality & Payment Reform. Reducing hospital readmissions. http://www.chqpr.org/readmissions.html
7. Suter P, et al. Theory-based telehealth and patient empowerment. Popul Health Manage. 2011;14(2):87-92.
8. U. S. Department of Health and Human Services. Telehealth. http://www.hrsa.gov/ruralhealth/about/telehealth/
9. Hein MA. Telemedicine: An Important Force in the Transformation of Healthcare. 2009. http://ita.doc.gov/td/health/telemedicine_2009.pdf
10. Clark RA, et al. Telemonitoring or structured telephone support programmes for patients with chronic heart failure: Systematic review and meta-analysis. BMJ. 2007;334(7600):942-945.
11. Inglis SC, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev. 2010;8:CD007228.
12. Seto E, et al. Mobile phone-based telemonitoring for heart failure management: A randomized controlled trial. J Med Internet Res. 2012;14(1):e31.
13. Bowles KH, et al. Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: A randomized controlled trial. Int J Telemed Appl. 2011;2011:540138.
14. Venter A, et al. Results of a telehealth-enabled chronic care management service to support people with long-term conditions at home. J Telemed Telecare. 2012;18(3):172-175.
15. Gellis ZD, et al. Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial. Gerontologist. 2012;52(4):541-552.
16. McManus SG. A telehealth program to reduce readmission rates among heart failure patients: One agency's experience. Home Health Care Manage Pract. 2004;16(4):250-254.
17. Espensen M. Communication techniques. In: Espensen M, ed. Telehealth Nursing Practice Essentials. Pitman, NJ: American Academy of Ambulatory Care Nursing; 2009:45-45-66.
18. Malcolm J, Arnold O. Heart failure. http://www.merckmanuals.com/home/heart_and_blood_vessel_disorders/heart_failure/heart_failure.html
19. Texas Statewide Health Coordinating Council. The state of TeleMedicine and TeleHealth in Texas: A special report of the Texas Statewide Health Coordinating Council and recommendations for ensuring a strong Telemedicine/Telehealth system in Texas. 2002.
20. Mayo Clinic. Mayo clinic: Heart failure definition. http://www.mayoclinic.com/health/heart-failure/DS00061
21. Lobodzinski SS, Jadalla AA. Integrated heart failure telemonitoring system for homecare. Cardiol J. 2010;17(2):200-204.
22. Colucci WS. Patient information: Heart failure (beyond the basics). http://www.uptodate.com/contents/heart-failure-beyond-the-basics
Mari Tietze is a nurse informaticist who is an associate professor at Texas Woman's University in Dallas. Mary Reeves, Dona Horton and Rebecca Wolfe graduated from the family nurse practitioner program at Texas Woman's University in May 2013.