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CE Professional Case Management Vol. 20, No. 4, Copyright 2015 Wolters Kluwer Health, Inc. All Rights Reserved. Hearing the Veteran s Voice in Congestive Heart Failure Readmissions Carl W. Stevenson,
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CE Professional Case Management Vol. 20, No. 4, Copyright 2015 Wolters Kluwer Health, Inc. All Rights Reserved. Hearing the Veteran s Voice in Congestive Heart Failure Readmissions Carl W. Stevenson, RN, BSN, Daria Pori, RD, DSO, Kattie Payne, PhD, MSN, RN, Mary Black, RN, MSN, and Victoria E. Taylor, BSN, MSA ABSTRACT Purpose/Objective: Our purpose was to examine congestive heart failure (CHF) readmissions from the veterans perspective. The use of health care provider interventions, such as standardized education materials, home telehealth, and a CHF clinic, was able to reduce readmissions rates from 35% to 23%. Our objective was to use input from the veterans to fine-tune our efforts and achieve readmission rates for patients with CHF below the national average of 21%. We wanted to identify factors that result in CHF readmissions, including disease education, self-care management, and barriers to self-care. This study was directed toward answering two questions: 1. What is the veteran s explanation for readmission? 2. According to the veteran, what are the barriers to following their treatment regimen? Primary Practice Setting: It was a rural 84-bed Veterans Health Administration hospital in the Western United States. Findings: Before this study, our efforts to reduce CHF readmissions were one-sided, all from the health care professionals viewpoint. We wanted to hear what the veteran had to say; so, we interviewed 25 veterans. Four veterans were excluded due to issues with their consents. Ninety percent ( n = 19/21) responded that they knew their CHF was worse by a change in their breathing (shortness of breath). They identified 48 signs/symptoms that indicated worsening CHF. Weight gain was noted as an indication of worsening CHF symptoms ( n = 6/48) in 12.5% of the responses. Twenty-five percent ( n = 12/48) of the veterans stated they recognized the early symptoms of worsening CHF. Thirty-eight percent ( n = 8/21) of the veterans stated they had early symptoms of worsening CHF, but only two of them contacted their doctor. It is interesting to note that only 29% ( n = 6/21) of the veterans recognized weight gain as a sign of worsening CHF and all of these veterans listed other symptoms (such as shortness of breath) along with weight gain. Weighing on a daily basis was practiced by only 30% of the group ( n = 7/21); all but two of the veterans had no problems with weighing themselves. More than 71% of the veterans responded that they had no problems following their diet or taking their medications. More than half of the veterans did not need help with meals, transportation, or daily grooming/dressing/toileting. Conclusions: We were concerned about the evident delays in seeking medical care for worsening CHF. All veterans who did need help with the activities of daily living, medications, or diet had their needs met through their support systems. They did not perceive any barriers to seeking care. However, there remain many unanswered questions. Does the patient understand their discharge education and know how to use this information from daily weights or recognition of early symptoms, to indicate their need for urgent and emergency medical interventions? Or is it a problem that the education is not sufficient? Is it a question of the burden of care from multiple comorbid conditions or of taking too many medications? Do social issues drive readmissions? These questions are further explored in a second study, which is in the data analysis stage. Implications for Case Management Practice: There are three key findings from our study. 1. Veterans think in terms of symptoms that increase the impact of CHF on their life. 2. The relationship between daily weight and controlling CHF is not clear to veterans. 3. Hospital discharge instructions should clearly associate symptoms that are associated with worsening CHF. Key words: CHF, readmissions, veterans perspective Our facility is a small, rural Veterans Hospital located in the Western United States. From 2009 to 2010, our hospital had 1003 veteran admissions for congestive heart failure (CHF). Of these, 355 or 35% had readmissions; we were well above the national average of 21% for the CHF The authors report no conflicts of interest. Address correspondence to Carl W. Stevenson, RN, BSN, Boise VA Medical Center, 500 West Fort Str, Boise, ID ( ). DOI: /NCM Vol. 20/No. 4 Professional Case Management 177 readmission rate. This really caught our attention. As nurses and dietitians in the inpatient area, we wanted to know why these patients were having such frequent readmissions, and, more importantly, how we could help prevent them. BACKGROUND Heart disease is the most expensive cause of morbidity and death in the United States. More than 5 million people have some degree of CHF, of which about 50% of these people will die within 5 years of diagnosis. CHF costs the United States about $32 billion in health care expenditures each year ( Go et al., 2013 ). Estimates indicate that CHF is the single most common reason for hospital admissions among older adults and results in about 6.5 million days in the hospital each year ( Lopert et al., 2012 ). A review of the literature review revealed key reasons for CHF readmissions as being the complexity of the disease and its interaction with comorbid conditions, the difficulties associated with coordination of multidisciplinary health care, and the poor outcomes patients often experience. COMPLEXITY AND COMORBID CONDITIONS CHF is a complex syndrome resulting from various structural or functional heart problems that impair the ventricles ability to fill with, or eject, blood. Although about 50% of the people with CHF die within 5 years after diagnosis, early diagnosis and adequate treatment can lengthen life expectancy and improve the quality of life. Treatment involves a daily regimen of medications, low-sodium diet, and physical exercise. In addition, the treatment must be tailored to the underlying cause of the condition and the heart failure stage, as well as the individual s comorbid conditions ( National Clinical Guideline Centre, 2010 ). Most patients with CHF have other chronic health problems, as well. Reports show that more than 80% of patients with heart failure older than 65 years have four or more comorbid conditions ( Van der Wel et al., 2007 ). The literature revealed that a universal lack of understanding related to signs of a worsening condition and when to seek appropriate health care were just as prevalent as the lack of understanding regarding the disease and its prognosis. This literature review also noted the heavy burden of self-care management on the patient and his/ her condition. Dietary and fluid restrictions and daily weighing were noted as problematic in these patients who struggled with unquenchable thirst and the need to restrict fluids. In addition, with multiple comorbid conditions, these patients often dealt with medication side effects and medication interactions ( Annema, Luttik, & Jaarsma, 2009 ). HEALTH CARE EFFORTS Many efforts have been made to improve the CHF patient s outcomes. These have been directed toward optimizing the patient s treatment as the disease progresses, educating the patient for self-care to improve their adherence to treatment, and close follow-up by a health professional ( Gwadry-Sridhar, Flintoft, Lee, Lee, & Guyatt, 2004 ; Kim & Han, 2013 ). The Veterans Health Administration (VHA) implemented two initiatives to address the care of veterans with CHF. The first was a comprehensive CHF toolkit for providers to use when treating veterans with the condition. This toolkit focused on key parts of CHF management and included algorithms for medical management and patient discharge self-care instructions, covering medication, diet restrictions, weighing daily, and activity level ( VA Quality Enhancement Research Initiative, 2010 ). The second initiative was the Hospital to Home (H2H) program. The H2H program was developed collaboratively with the Institute for Healthcare Improvement and the American College of Cardiology to reduce CHF readmission rates. The focus areas for the H2H program were medication management (e.g., patient is competent with their medication regimen), early follow-up after hospital discharge (e.g., scheduling follow-up appointments within a week of discharge), and symptom management (e.g., assuring that the patient knows when to call for medical attention and who to contact) ( Hospital to Home, 2013 ). RISING HOSPITAL READMISSIONS Despite these efforts toward improving care for patients with CHF, hospital readmissions for CHF have continued to rise. In 2008, the National Institutes of Health sponsored a clinical trial called the Heart Failure Adherence and Retention Trial to compare deaths and CHF hospitalizations between a patient self-management skills training with a CHF education group and a CHF education alone group ( Powell et al., 2008 ). Results from the study indicated no difference between the patient groups with regard to death rates, hospitalizations, or quality of life ( Powell et al., 2010 ). STUDIES OF READMISSIONS Annema et al. (2009) conducted the first study to examine hospital readmissions of patients with CHF from different perspectives: patient, caregiver, cardiologist, and the nurse. Several reasons for readmission were identified, including worsening symptoms, comorbid health conditions, and lack of compliance with treatment (such as nonadherence to diet, fluid restrictions, or 178 Professional Case Management Vol. 20/No. 4 medications). Inadequate medications for treating the disease and inadequate help from health professionals were also identified as factors that led to readmission. The findings also indicated that 23 31% of the readmissions were believed to be preventable. This study found that patients, care givers, and health professionals did not always agree regarding the reason for readmission (Granger, Sandelowski, Tahshjain, Swedberg, & Ekman, 2009). This disagreement may be the underlying factor that interferes with the patient s ability to carry out the treatment plan on a daily basis. These findings imply that patient education should focus on recognition of symptoms and appropriate actions for those symptoms to decrease hospital readmissions. Several patient factors have been identified as significantly related to hospital readmissions. Shippee, Shah, May, Mair, and Montori (2012) designed a patient-centered model for patient complexity (cumulative complexity model) that considers clinical and social factors that shape access, utilization, self-care, and health for the individual patient. The patient complexity factors were categorized into two areas: workload (demands on the patient time and energy) and capacity (personal resources, social support, and abilities and limitations). Workload and capacity interactively affect the patient s ability to access and utilize health care resources, as well as perform self-care related to their disease. Multiple health conditions compound this burden for the patient. PATIENT EDUCATION Strengthening patient education can improve selfcare behaviors and decrease readmissions to the hospital. One VHA medical center formed an interdisciplinary team to develop and implement an outpatient heart failure education program in an effort to improve patient compliance with treatment. A study compared the usual education provided for discharged patients with the education provided by an interdisciplinary team in a group setting. Their findings supported interdisciplinary education decreasing the 30-day readmission rate, but at 60 and 180 days, there was a gradual increase in their reported readmission rates ( Gerdes & Lorenz, 2013 ). Other studies identified various reasons patients with CHF do not comply with their treatment. Reasons for not complying with the medications include expense, attitudes about medications, effects on sexual function, and not being convinced that the medication helps their condition. Other reasons for not complying with treatment include having other chronic conditions that require self-care, poor health care literacy, depression, and personal cultural factors. Reasons for not complying with the medications include expense, attitudes about medications, effects on sexual function, and not being convinced that the medication helps their condition. Other reasons for not complying with treatment include having other chronic conditions that require self-care, poor health care literacy, depression, and personal cultural factors ( Crocker, Crocker, & Greenwald, 2012 ; Steele et al., 2010 ). Studies using self-report of medication adherence indicates that about 90% of patients take their medications as prescribed. On the other hand, Calvin et al. (2012) found that 37% of patients took less than 80% of their prescribed medications. FACILITY-SPECIFIC INTERVENTIONS Our facility s initial knee-jerk response to reduce CHF readmissions was to improve our patients knowledge by putting together a standardized discharge education packet. The packets included educational materials and a checklist to ensure that the education was completed before discharge. In addition, providers enrolled veterans with CHF in the Care Coordination Home Telehealth (CCHT) program and referred them to a newly opened outpatient CHF clinic. After these initiatives were put in place, the readmissions rate went to about 23%, but we wanted to do better. We went back to the drawing board, and decided we needed more information. So we decided to look at the part of the equation we had not considered, namely what Our facility s initial knee-jerk response to reduce CHF readmissions was to improve our patients knowledge by putting together a standardized discharge education packet. After these initiatives were put in place, the readmissions rate went to about 23%, but we wanted to do better. So we decided to look at the part of the equation we had not considered, namely what our patients thought was contributing to their readmission. Thus evolved our patient interview study. Vol. 20/No. 4 Professional Case Management 179 our patients thought was contributing to their readmission. Thus evolved our patient interview study. METHODS Design Our study was a qualitative design in which we interviewed 25 patients readmitted for CHF during Setting We are a small, rural VHA medical center that is the main source of medical treatment for about 94,000 veterans living in our service area. Some of those veterans are from larger urban areas, but most come from small towns and outlying farms and ranches, and finally some of these veterans are homeless. The local VHA leadership, the institutional review board, and the Boise Research and Development Committee approved the study. Procedure To help us design the study, we used a report from the Institute for Healthcare Improvement and Robert Wood Johnson Foundation, How-to Guide: Creating an Ideal Transition Home for Patient With Heart Failure. This report was part of the Transforming Care at the Bedside national program to improve the quality and safety of patient care on medical and surgical units, to increase the vitality and retention of nurses, and to improve the effectiveness of the entire care team ( Nielsen et al., 2008, pg. 1). Because our goal was to find out what our veterans, with CHF, thought contributed to their readmission to the hospital, we developed a short questionnaire (based on the How-to Guide ) that asked about the patient s recognition of symptoms, perceived barriers to care, and what they perceived caused the readmission. Then, we interviewed patients readmitted from January through May All patients had CHF as a primary or secondary diagnosis. The patients signed a consent form at the time of the interview. RESULTS We interviewed 25 veterans in their hospital rooms. We had to exclude four interviews because of problems with the consents. Of the 21 veterans whose information we could use, only four were readmitted with a primary diagnosis of CHF. The rest of the veterans had secondary diagnoses of CHF. The veteran interview questionnaire contained seven questions. We have presented the information gathered from each question individually. TABLE 1 Veteran Responses to Question 1: Reason for Readmission (n = 21) It s probably nothing that I ate or drank, probably more worrying about going belly up Loss of breath 3 months ago when they switched my medication I could feel my breathing getting worse My doctor cut my Lasix back. My swelling increased in my legs. It kept getting worse and I got short of breath I had coughing and trouble breathing, I think it started with my lungs, I gained fluid weight I had a PA, change my medication, and take my water pill out of the meds. Ongoing heart problem, there is nothing they can do to fix it My oxygen count was low, they found at today s doctor s appointment Smoking I guess, my lung overtaxed my heart, maybe exertion I had chest pain and shortness of breath I was having coughing, shortness of breath, and wheezing I couldn t breathe, my lungs were filling up with fluid I smoked too many cigarettes They did not take off as much fluid during dialysis for a month or so. I was getting short of breath This time I was coughing and I passed out. I was driving my car and I passed out I let it go until I was too uncomfortable to go any longer Infection to left foot, atrial fibrillation caused my heart to get stressed My legs swelled Had a heart attack My breathing was worse I went blank, I passed out Question One: How Do You Think You Became Sick Enough to Be Readmitted to the Hospital? Some veterans identified more than one cause for their readmission. Their answers revealed that they viewed the readmission in terms of their symptoms, with shortness of breath or breathing difficulty being the primary symptom reported (9 of the 21 responses). Table 1 contains the veteran responses to question 1. Question 2: Was There a Doctor Office Visit Scheduled Before This Admission to the Hospital? It was interesting to note that over half of the veterans ( n = 12 or 57%) had a scheduled office visit before this admission. Conversely, nine patients (43%) did not have a prior scheduled office visit. The second half of question 2 pertained to whether the veteran perceived problems with scheduling or getting to the clinic appointment. One veteran responded that he was confused about the appointment date. Another stated he had had several 180 Professional Case Management Vol. 20/No. 4 appointments during that month for the same problem. A third stated that he had gone to the emergency department and a fourth stated that he had difficulty walking. The responses revealed no common difficulties with either scheduling an appointment or being able to get to the appointment. Questions 3: How Often Have You Weighed Yourself Since Your Last Admission to the Hospital? For this question, only 17 interviews were completed because four of the veterans received a prior approved questionnaire that did not contain this question. Six of the 17 veterans (35%) weighed themselves daily, four (24%) weighed weekly, two (12%) weighed two to three times per week, and three (18%) weighed four to five times per week. Only one veteran did not weigh himself at all. Table 2 presents the responses for frequency of weighing among the veterans. The second half of question 3 asked whether the veteran had problems weighing himself. Only two responded that they had problems, and each of those stated that someone in their assisted living home weighed them. Questions 4: Have Any of the Following Interfered With Your Ability to Follow the Diet Your Doctor Prescribed for You? Fifteen veterans (71%) responded that they had no problems following the prescribed diet. Three responded that the assisted living home handled their diet and two responded that transportation interfered with their
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