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Testing the Effect of a Home Health
Heart Failure Intervention on Hospital
Readmissions, Heart Failure Knowledge,
Self-Care, and Quality of Life
Mary Ann Leavitt, PhD, RN, CHFN-K, CCRN-K; Debra J. Hain, PhD, ARNP, AGPCNP-BC, FAANP, FNKF;
Kathryn B. Keller, PhD, RN, CNE; and David Newman, PhD, MA, MS
ABSTRACT
For older adults, heart failure (HF) has the highest 30-day hospital readmission rate
of any chronic illness. Despite research into strategies to reduce readmissions, no
single program has emerged as sustainable. The purpose of the current study was
to test a researcher-developed home health nurse HF intervention (CareNavRN™) on
30-day readmission rates, HF knowledge, self-care, and quality of life (QOL) among
40 older adults transitioning home. Home health nurses received specialized HF
training and visited patients once per week at home for 4 weeks. The control group
(n = 21) had six readmissions (29%) and the intervention group (n = 19) had three
readmissions (16%); however, the results were underpowered and statistically non-
signifi cant. Pre-/post-surveys demonstrated signifi cant improvement in HF knowl-
edge (p = 0.043), self-care confi dence (p = 0.003), and QOL (p < 0.001) in the inter-
vention group. CareNavRN is a promising approach to improve outcomes during
transition from hospital to home for patients without access to a comprehensive
disease management program. [Journal of Gerontological Nursing, 46(2), 32-40.]
There are more than 6.2 million
adults in the United States
with heart failure (HF), with
projected growth to >8 million by
2030, including a substantial in-
crease in HF incidence and preva-
lence in older adults (Benjamin et
al., 2019). Despite improvements
in guideline-directed therapy for
HF, it remains a frequent reason
for hospitalization of older adults
(Jalnapurkar et al., 2018). From
2001 to 2014, 75.3% of all adults
hospitalized with a primary or sec-
ondary diagnosis of HF were age
≥65 (Akintoye et al., 2017).
Care transitions and unplanned re-
admissions have been at the forefront
of health policy discussions since
2009 when a retrospective analysis
of >11 million Medicare bene cia-
ries revealed that approximately 20%
were readmitted within 30 days of
hospital discharge (Jencks, Williams,
& Coleman, 2009). HF is the most
frequent diagnosis linked to 30-day
readmissions; between 20% and 25%
of patients discharged with HF will
return to the hospital within 30 days
(Jalnapurkar et al., 2018). Readmis-
sion risk for patients with HF increas-
es each year after age 55 (Whellan
et al., 2016). Although the United
States’ Healthcare Readmission Re-
duction Program (HRRP) legislation
has demonstrated some success in re-
ducing HF readmissions, it has also
been associated with an alarming in-
crease in HF mortality (Gupta et al.,
2018). e HRRP may have incen-
tivized hospitals to discharge patients
in a way that might actually decrease
their survival, which is an important
reason to determine the best strategy
for older adults transitioning from the
hospital to home (Gupta et al., 2018).
Successful transition to home with
HF involves self-care activities, such
Dr. Leavitt is Assistant Professor, Dr. Hain
is Blake Distinguished Professor, Dr. Keller is
Professor & Graduate Coordinator Nurse Ed-
ucator Concentration, and Dr. Newman is As-
sociate Professor and Statistician, Christine
E. Lynn College of Nursing, Florida Atlantic
University, Boca Raton, Florida.
The authors have disclosed no potential
confl icts of interest, fi nancial or otherwise.
Address correspondence to Mary Ann
Leavitt, PhD, RN, CHFN-K, CCRN-K, Assistant
Professor, Christine E. Lynn College of Nurs-
ing, Florida Atlantic University, 777 Glades
Road, NU 344, Boca Raton, FL 33431; e-mail:
mleavit3@health.fau.edu.
Received: April 2, 2019
Accepted: September 6, 2019
doi:10.3928/00989134-20191118-01
32 Copyright © SLACK Incorporated
as medication management, diet
and weight monitoring, exercise, at-
tention to worsening symptoms,
and knowledge of when to contact a
health care provider (Riegel, Dickson,
& Faulkner, 2016). Although this
information is included in standard
discharge education, older adults may
have di culty understanding the dis-
ease process (i.e., HF knowledge) and
adapting to new dietary and medica-
tion regimens (i.e., HF self-care) as
they transition home (Hain, Tappen,
Diaz, & Ouslander, 2012; Riegel et
al., 2016). In addition, the stress of
hospitalization, including sleep de-
privation, physical deconditioning,
and nutritional de cit, contributes to
the generalized vulnerability of older
adults who are recently discharged
(Krumholz, 2013).
Recognizing that ine ective transi-
tions are a risk factor for 30-day HF
readmissions in older adults, many
researchers have focused their inter-
ventions on the transition process.
Studies have demonstrated some im-
provement in outcomes, but all with
limitations. One challenge has been
hospital sta nurse time for discharge
education (Albert et al., 2015). Even
though discharge teaching can help
reduce the risk for 30-day readmis-
sion (Kommuri, Johnson, & Koelling,
2012), most hospital nurses spend no
more than 5 to 15 minutes on this
important task (Albert et al., 2015).
Alternatively, some researchers
have sought to address HF readmis-
sions through telephone follow up or
telemonitoring, with mixed results. In
one study, post-discharge telephone
calls by lay navigators only slightly
reduced readmissions in older adults
(Balaban et al., 2015); in another
study, a combination of health coach-
ing telephone calls with telemonitor-
ing yielded no signi cant di erence in
readmissions (Ong et al., 2016); and
a systematic review and meta-analysis
of HF telemonitoring randomized
controlled trials (RCTs) revealed
no reduction in all-cause readmis-
sions (Inglis, Clark, Dierckx, Prieto-
Merino, & Cleland, 2015). ese
ndings support the need for a dif-
ferent approach to this complex issue,
such as face-to-face relational connec-
tion with older adults transitioning
home with HF.
e importance of a face-to-face
connection was highlighted in several
systematic reviews of HF transitional
care interventions with older adults
(Van Spall et al., 2017; Verhaegh et
al., 2014). One of the most impor-
tant aspects that led to improved
clinical outcomes (i.e., decreased
30-day readmissions) was the indi-
vidual post-discharge support that
reinforced self-care (Van Spall et al.,
2017). Some studies have provided
this support by combining multidis-
ciplinary discharge education with
home visits, and although promising,
it has been di cult to determine the
critical elements of the intervention
(Stamp, Machado, & Allen, 2014;
Vedel & Khanassov, 2015). Several
studies on HF transitional care have
demonstrated that nurse-driven tran-
sitional programs, with at least weekly
contact, were one of the best ways to
reduce 30-day readmission (Van Spall
et al., 2017; Verhaegh et al., 2014).
Advanced practice nurses (APNs)
who received extensive geriatric train-
ing and made frequent home visits
over 3 months markedly decreased
readmissions of older adults at 1 year,
but the program cost was approxi-
mately double that of routine home
care (Naylor et al., 2004).
Educating home health RNs in the
specialized care of older adults who are
transitioning home with HF may be
an e ective strategy to improve self-
care and reduce 30-day readmissions.
Experienced home health nurses have
a particular skill set and comfort level
to assess and educate patients in their
own environment; these elements
could be especially useful for tran-
sitioning recently discharged older
adults with HF. With additional edu-
cation and training in HF manage-
ment, home health nurses may be the
answer, yet there is lack of evidence to
support this potentially cost-e ective
approach. In response to this need,
the current investigator developed
an intervention (CareNavRN™) for
home health nurses to receive special-
ized HF education and visit a sample
of older adult patients before and af-
ter hospital discharge. e purpose of
the current study was to examine the
e ect of the CareNavRN interven-
tion on 30-day hospital readmissions,
HF knowledge, HF self-care, and HF
quality of life (QOL) in older adults
(i.e., age ≥65 years) with HF.
METHOD
Design
e current study was a RCT
of 40 older adults recruited from a
400-bed not-for-pro t hospital in
the southeastern United States. Each
participant had a primary or second-
ary diagnosis of HF and was random-
ized into an intervention (n = 19)
or control (n = 21) group. Initially,
76 patients were planned with 38 in
each group (p = 0.05; power = 80;
odds ratio = 2.12). Due to recruit-
ment challenges and potential in u-
ence of a larger competing study with
the same population, the sample was
limited to 40. e hospital research
committee and the researcher’s uni-
versity Institutional Review Board ap-
proved the study protocols.
Procedure
Potential participants were identi-
ed from a daily report generated by
the hospital’s Quality Improvement
Department, which tracked patients
with indicators of high readmission
risk diagnoses. For patients with
HF indicators (e.g., elevated pro-B-
type natriuretic peptide, radiology
reports, diuretic medications), the
electronic medical record (EMR) was
reviewed by the investigator for a HF
diagnosis. Inclusion criteria for the
current study were: (a) score ≥3 on
the Mini-Cog™, a three-item word-
learning and recall task with a clock-
drawing distractor before word recall
(Borson, Scanlan, Chen, & Ganguli,
2003); (b) age ≥65; (c) a primary
or secondary diagnosis of HF; and
(d) residence within 20 miles of the
33
Journal of Gerontological Nursing | Vol 46 | No 2 | 2020
hospital for at least 30 days after dis-
charge. Patients unable to participate
in pre-/post-testing (i.e., those who
were non-English-speaking, had se-
vere and uncorrected hearing loss, or
dementia) were excluded. Informed
written consent was obtained, and pa-
tients were randomly assigned to the
intervention or control group using a
random number table. e group as-
signment was not known until after
consent and randomization.
RNs who delivered the interven-
tion were invited from the sta of the
hospital’s home health department.
ese nurses had an interest in cardi-
ology and at least 2 years of experience
in home health. Six nurses volun-
teered for the study and all attended
6 hours of HF education based on the
Heart Failure Nursing Certi cation
Core Curriculum Review (Paul &
Kirkwood, 2015) taught by the inves-
tigator, who is a certi ed HF nurse.
ey were trained in the CareNavRN
study protocol and instrumentation.
CareNavRN Intervention
Patients in the intervention group
received one visit in the hospital by
the CareNavRN nurse followed by
four visits by that same nurse over
30 days post-discharge (Table A,
available in the online version of this
article). e intention of using the
same nurse was to facilitate rapport
and develop the nurse/patient rela-
tionship. In most cases, each nurse
made the initial visit in the hospital
to meet the patient and provide a HF
education booklet. If study enroll-
ment occurred on discharge day be-
fore the home health nurse was able to
get to the hospital, she then called the
patient before discharge (n = 4). If the
patient was cognitively impaired and
a cohabiting family caregiver was in-
terested in participating in the study,
Mini-Cog and informed consent was
obtained from the caregiver and edu-
cation was provided to the patient and
caregiver (n = 2). All patients were vis-
ited at home within 72 hours of dis-
charge, with most being seen within
24 hours of discharge. A home visit
within 3 days is one component of
care shown to decrease 30-day read-
mission rates (Verhaegh et al., 2014).
e CareNavRN nurse provided
HF teaching, including pathophysi-
ology, symptoms, and medications,
according to a teaching plan that ac-
companied a patient education book-
let. During each home visit, the nurse
performed a physical assessment, ex-
amined the home environment, and
talked with the patient about how he/
she was assimilating the HF discharge
instructions into daily life (Table A).
e investigator, who accompanied
each CareNavRN nurse on at least
one home visit, assessed delity to the
study protocol.
e control group received usual
care, which comprised printed and
verbal HF discharge education de-
livered by the primary hospital RN.
e intervention and control groups
received home health care, as is usual
for patients with a HF diagnosis. In
addition, the intervention group re-
ceived the CareNavRN intervention.
Instruments
During the initial hospital contact,
the investigator obtained informed
consent, collected baseline data, and
reviewed the EMR. Health indicators
measured to ensure comparability of
groups at baseline included the vari-
ables of depression (Geriatric Depres-
sion Scale-15; Sheikh & Yesavage,
1986), functional status (Lawton
Activities of Daily Living Scale; Graf,
2008), and health literacy (Newest
Vital Sign; Weiss et al., 2005). e
CORE calculator, a statistical model
developed from chart data abstraction
(Yale-New Haven Hospital Center for
Outcomes Research and Evaluation,
2012), measured readmission risk.
e primary outcome of 30-day
hospital readmission post-discharge
was determined by patient self-report
at each visit for the intervention group
and with a post-survey for the control
group. Self-report for both groups was
validated by EMR review. Secondary
outcomes of HF knowledge, self-care,
and QOL were measured at enroll-
ment and 30 days post-discharge. e
Dutch HF Knowledge Scale, a widely
used 15-item multiple-choice ques-
tionnaire on HF physiology, measured
HF knowledge and management.
is scale has a reported Cronbach’s
alpha of 0.62 (van der Wal, Jaarsma,
Moser, & van Veldhuisen, 2005).
Self-care was measured by the Self-
Care of HF Index (SCHFI) v.6.2, a
22-item, 4-point Likert scale measur-
ing the three self-care components of
maintenance, management, and con-
dence (Riegel, Lee, Dickson, & Carl-
son, 2009). Of 100 possible points, a
score ≥70 on each scale is considered
adequate self-care. e HF main-
tenance scale (alpha = 0.55) helps
evaluate a patient’s daily activities to
prevent worsening symptoms, such
as diet, medication adherence, and
monitoring of weight and edema. e
HF management scale (alpha = 0.60)
measures a patient’s response to wors-
ening symptoms, such as di culty
breathing or edema. e HF con -
dence scale (alpha = 0.82) registers a
patient’s perceived ability to remain
symptom-free, follow treatment ad-
vice, recognize changes, and respond
promptly (Riegel et al., 2009). As the
SCHFI includes several dimensions
of self-care, Cronbach’s alpha may not
be the best measure of internal consis-
tency. In later testing, exploratory fac-
tor analysis identi ed sub-dimensions
and con rmatory factor analysis indi-
cated an excellent t in all three scales
(Vellone et al., 2013).
QOL was measured by the Minne-
sota Living with HF Questionnaire,
a 21-item, 6-point Likert scale. is
scale measures the physical, psycho-
logical, and social impact of HF, with
reported Cronbach alphas >0.80 for
all scale items (Heo, Moser, Riegel,
Hall, & Chrisman, 2005).
Data Analysis
To assess any potential di erences
between the intervention and control
groups on demographic characteris-
tics, chi-square tests were conducted
on categorical sociodemographic and
clinical variables. Likewise, to assess
34 Copyright © SLACK Incorporated
any potential di erences at baseline
between these groups on the outcome
variables (i.e., HF knowledge, self-
care, and QOL), independent sample
t tests were used. To test the e ective-
ness of the CareNavRN intervention
on the reduction of 30-day hospital
readmission rates between the inter-
vention and control groups, a chi-
square test was used, as the outcome
was a 2x2 contingency (Field, 2018).
e overall e ectiveness of the
CareNavRN intervention over time
was assessed using a repeated mea-
sures analysis of variance (ANOVA)
for measures of HF knowledge, three
constructs of HF self-care, and HF
QOL while controlling for individ-
ual di erences. Repeated measures
ANOVA is the most appropriate test
because it controls for the dependence
of measurement when tests are repeat-
ed over time (Stevens, 2009). Family-
wise adjustments were used for the
self-care scales.
RESULTS
ere were no signi cant dif-
ferences in baseline demographics,
clinical characteristics, calculated
readmission risk, or baseline out-
come measures for the two groups
(Table 1). Mean participant age was
82.7 years (SD = 8.27 years), 52.5%
were male, and 97.5% were White/
non-Hispanic. Most patients had a
primary diagnosis (65%) as well as a
history (63%) of HF. One patient in
the intervention group dropped out
after the rst in-hospital CareNavRN
visit, citing stress of her hospital
course. Although the patient was not
readmitted, she did not receive any
home visits and was excluded from
analysis.
Hospital readmissions within
30 days occurred in six (29%) patients
in the control group and three (16%)
patients in the intervention group,
although results were underpowered
and non-signi cant. HF knowledge
improved signi cantly over time in
the intervention group (p = 0.043).
Self-care maintenance (p = 0.071) and
management (p = 0.480) improved
TABLE 1
Categorical Variables by Treatment Group (N = 40)
Variable
Control
Group
(n, %)
(n = 21)
Intervention
Group
(n, %)
(n = 19) p Value
Gender 0.921
Female 10 (47.6) 9 (47.4)
Male 11 (52.4) 10 (52.6)
Race/ethnicity 0.436
White/non-Hispanic 21 (100) 18 (97.5)
White/Hispanic 0 1 (2.5)
Education level 0.573
Some high school 2 (9.5) 0
Graduated high school 5 (23.8) 4 (21.1)
Some college 6 (28.6) 5 (26.3)
Graduated college 4 (19) 7 (36.8)
Master’s degree 2 (9.5) 2 (10.5)
Doctorate degree 2 (9.5) 1 (5.3)
Marital status 0.480
Married 12 (57.1) 9 (47.4)
Widowed 6 (28.6) 7 (36.8)
Divorced 2 (9.5) 3 (15.8)
Single/never married 1 (4.8) 0
Lives with 0.479
Spouse 10 (47.6) 8 (42.1)
Alone 6 (28.6) 9 (47.4)
Children 2 (9.5) 2 (10.5)
Signifi cant other 1 (4.8) 0
Other family member 1 (4.8) 0
Friends 1 (4.8) 0
Hospital LOS (days) 0.830
1 to 3 8 (38.1) 6 (31.6)
4 to 5 10 (47.6) 8 (42.2)
6 to 10 2 (9.6) 3 (15.8)
11 to 20 1 (4.8) 2 (10.5)
ICU admission 0.709
No 19 (90.5) 18 (94.7)
Yes 2 (9.5) 1 (5.3)
35
Journal of Gerontological Nursing | Vol 46 | No 2 | 2020
over time in both groups. HF self-care
con dence improved signi cantly
over time in the intervention group
(p = 0.003). HF QOL demonstrated
signi cant improvement over time in
the intervention group (p < 0.001)
(Table 2). Of the three variables that
improved over time, only QOL sig-
ni cantly predicted readmission like-
lihood in both groups, irrespective of
intervention (χ2[1] = 3.86, p = 0.049,
Nagelkerke R2 = 0.17].
A post-hoc analysis was conducted
to assess for outcome di erences re-
lated to timing of the rst home visit
(within 24 hours vs. 24 to 72 hours).
Four patients who received a tele-
phone call versus meeting the Care-
NavRN nurse in the hospital were
also analyzed post-hoc. ere was
no signi cant di erence in readmis-
sions (χ2[1] = 0.18, p = 0.671) or
any signi cant di erence in change
over time for other outcomes regard-
ing home visit timing (p = 0.555 to
0.845) or hospital visit/telephone call
(p = 0.446 to 0.885).
DISCUSSION
Readmissions
ere were only one half as many
readmissions in the intervention
group compared to the control group.
It was originally hypothesized that im-
provement over time in the secondary
outcomes related to the intervention
would also result in fewer readmis-
sions. Unfortunately, the study was
underpowered, and the results were
non-signi cant. is intervention
may provide an approach to decrease
readmissions in older adults with HF,
although further testing with greater
numbers of participants should be
conducted before program initiation.
e CareNavRN intervention
uniquely combines three components
that have individually demonstrated
e ectiveness in reducing readmis-
sions in prior studies. e rst com-
ponent is the face-to-face relational
interaction between the health care
provider and patient, which has dem-
onstrated decreased hospital readmis-
sions in other HF studies (Van Spall
TABLE 1
Categorical Variables by Treatment Group (N = 40)
Variable
Control
Group
(n, %)
(n = 21)
Intervention
Group
(n, %)
(n = 19) p Value
HF diagnosis
Primary 12 (57.1) 13 (68.4) 0.721
Secondary 9 (42.9) 6 (31.6) 0.945
History of HF 0.307
Yes 12 (57.1) 13 (68.4)
No 9 (42.9) 6 (31.6)
Depression (score)a0.660
No (0 to 5) 16 (76.1) 16 (84.2)
Suggested (>5) 4 (19) 3 (15.8)
Yes (>10) 1 (4.8) 0
Functional status (score)b0.208
Low (1 to 3) 5 (23.8) 2 (10.6)
Moderate (4 to 6) 1 (4.8) 4 (21)
High (7 to 8) 15 (71.4) 13 (68.5)
Health literacy (score)c0.322
Likely limited (0 to 1) 2 (9.5) 0
Possibly limited (2 to 3) 2 (9.5) 1 (5.3)
Adequate (4 to 6) 17 (81) 18 (94.7)
Ejection fraction (%) 0.513
15 to 19 0 2 (10.5)
20 to 29 4 (19) 1 (5.3)
30 to 39 2 (9.5) 1 (5.3)
40 to 49 2 (9.5) 3 (15.8)
50 to 59 9 (42.9) 9 (47.3)
60 to 69 3 (14.3) 3 (15.8)
70 to 79 1 (4.8) 0
Calculated readmission risk (%) 22.7 (4.5) 22.9 (4.7) 0.901
Note. LOS = length of stay; ICU = intensive care unit; HF = heart failure.
a Measured by the Geriatric Depression Scale-15; total score ranges from 0 to 15, with
scores >5 suggestive of depression and ≥10 almost always indicative of depression.
b Measured by the Lawton Activities of Daily Living Scale; total score ranges from 0
(low function, dependent) to 8 (high function, independent) .
c Measured by the Newest Vital Sign; total score ranges from 0 to 6, where 0 to 1 = high
likelihood of limited health literacy, 2 to 3 = possibility of limited health literacy, and
4 to 6 = adequate health literacy.
(CONTINUED)
36 Copyright © SLACK Incorporated
et al., 2017). Secondly, home visits
are an e ective way to assess imple-
mentation of discharge instructions
(Stamp et al., 2014; Verhaegh et al.,
2014). Weekly patient contact is the
third component of the CareNavRN
intervention. is was supported by a
recent review of interventions to pre-
vent readmissions, which indicated
that potential patient challenges must
be assessed prior to discharge and that
transitional care programs should in-
clude some type of weekly follow-up
contact (Ziaeian & Fonarow, 2016).
Heart Failure Knowledge
e current results indicated sig-
ni cant improvement in change over
time for HF knowledge in the inter-
vention group compared to the con-
trol group. Knowledge de cit contin-
ues to be a problem in many patients
hospitalized with HF. Only 10% of
patients discharged from a hospital
with a high-volume disease manage-
ment program understood all six dis-
charge educational topics required by
e Joint Commission (Regalbuto,
Maurer, Chapel, Mendez, & Sha er,
2014). A comprehensive understand-
ing of HF signs and symptoms has
been associated with improved self-
care (Lee, Moser, & Dracup, 2018).
In the CareNavRN intervention, pa-
tients not only received instructions
prior to discharge, but also received
reinforcement and additional instruc-
tion in the subsequent four home
visits.
Self-Care Confi dence
e CareNavRN intervention
demonstrated statistically signi cant
improvement in change over time
for HF self-care con dence in the
intervention group compared to the
control group. Adequate or improved
self-care con dence is associated
with improving day-to-day self-care
maintenance (Pancani et al., 2018).
Self-care con dence in older adults is
an important mediator between cog-
nition and self-care (Vellone et al.,
2015). Patients with adequate cogni-
tion may not be successful in self-care
due to low con dence, whereas those
with higher con dence may achieve
adequate self-care, even if cognitively
impaired (Vellone et al., 2015). is
nding underscores the importance
of con dence in self-care activities.
Addressing concerns on an individual
basis with a compassionate, caring,
and knowledgeable professional, who
can formulate self-care solutions, may
help boost con dence in a person
transitioning home with HF.
Home health nurses with special-
ized HF training were used in the
CareNavRN study and most of the
patient education and support took
place in the home. e CareNavRN
intervention demonstrated similar
self-care results as other studies us-
ing APNs (Graven, Gordon, Keltner,
TABLE 2
Control and Intervention Group Change Over Time for Heart Failure (HF) Knowledge,
Self-Care, and Quality of Life
Variable
Mean (SD)
Control Group Intervention Group
Pretest Posttest Pretest Posttest F(1,33) p Value η2
Dutch HF Knowledge
Scalea
10.71
(2.09)
11.76
(1.86)
11.33
(1.78)
13.44
(1.54)
3.13 0.043 0.09
SCHFIb
Maintenance 61.96
(14.72)
71.95
(17.16)
60.01
(14.99)
77.03
(14.81)
2.27 0.071 0.06
Management 34.41
(17.04)
48.12
(20.93)
42.50
(13.53)
53.14
(19.02)
0.00 0.480 0.00
Confi dence 62.13
(24.48)
62.82
(23.67)
56.84
(15.32)
83.38
(15.36)
10.69 0.003 0.25
Minnesota Living With
HF Questionnairec
44.65
(17.72)
55.12
(26.66)
58.39
(17.15)
28.94
(18.08)
38.63 <0.001 0.54
Note. SCHFI = Self-Care of Heart Failure Index.
a Total possible score = 15, ranging from 0 (no knowledge) to 15 (optimal knowledge).
b Total possible score = 100, with a score ≥70 considered adequate self-care.
c Total score range = 0 to 105, where lower scores indicate better quality of life.
37
Journal of Gerontological Nursing | Vol 46 | No 2 | 2020
Abbott, & Bahorski, 2018) or RNs
(Dalal et al., 2019; Van Spall et al.,
2017). e current ndings indicate
that placing more emphasis on the
home visit can make a di erence in
self-care con dence.
Quality of Life
e QOL results in the interven-
tion group were perhaps the most
striking ndings of the current study.
e average score of patients in the
control group indicated a signi cant
worsening of their QOL over time
(i.e., higher scores indicate worsening
QOL). It was surprising that the con-
trol group’s scores would decline to
such a degree. Conversely, the average
score of patients in the intervention
group indicated a signi cant positive
change over time associated with the
CareNavRN intervention. In other
studies on QOL during HF transi-
tions, control and intervention groups
experienced a generally positive e ect
on QOL (Stamp et al., 2014; Wang,
Dong, Jian, & Tang, 2017). Patients
who have relational support (such as
that provided by CareNavRN nurses)
and understand their medications,
dietary instructions, and exercise rec-
ommendations may be more likely
to believe that they can manage this
health challenge and experience im-
proved QOL (Rice, Say, & Betihavas,
2018).
PRACTICE AND RESEARCH
IMPLICATIONS
e challenge of HF readmissions
in older adults is multifaceted. Coor-
dinating care from hospital to home
involves improving communication
between the provider and patient, ed-
ucation of the patient and caregivers,
and monitoring of the patient in the
home environment. e supportive
nurse/patient relationship found in
the CareNavRN intervention may be
able to bridge this gap for older adults.
is intervention can help patients
become con dent in self-care and
understand what to do when symp-
toms worsen. If the CareNavRN role
was to become standard practice for
home health HF care, geriatric clini-
cians might refer appropriate patients
to this specialized program. Referral
to this program would be especially
important for older adults if there are
no local HF management programs
or if transportation is a barrier to their
participation.
Repeating this study with more
patients over a longer follow-up pe-
riod (6 to 18 months) is needed
to determine lasting e ects of the
CareNavRN approach. Speci cally
for readmissions, type II error could
be avoided by increasing the number
of participants and thereby increasing
statistical power. Implementing the
CareNavRN intervention with a more
diverse population would yield more
generalizable results. e addition of
an attention control group may help
elucidate which components of the
intervention were most e ective for
older adults with HF. It would also be
helpful to examine the QOL outcome
in light of the changes observed in the
intervention and control groups. Fur-
ther analysis of the impact of meeting
the CareNavRN nurse in the hospi-
tal is also warranted, as there was no
signi cant di erence in the outcomes
for the four patients who received a
telephone call and those who received
a visit.
LIMITATIONS
e CareNavRN study was a small,
single-center RCT with a homoge-
neous patient population, which along
with other variables, such as the time
spent in usual care discharge teach-
ing for the control group, could not
be controlled and consequently limits
generalizability. ere was no atten-
tion control group, so the results may
be due to the time the CareNavRN
nurse spent with the patient and not
necessarily the intervention itself. e
previously mentioned recruitment
challenges and competing study lim-
ited participants to 40, and as a result,
the study was underpowered. A larger
sample may have demonstrated statis-
tical signi cance for self-care mainte-
nance and readmissions. Regardless, it
is important to note any decrease in
readmissions, and the potential ben-
e ts of the nurse/patient relationship
in the CareNavRN intervention in-
vites further research.
CONCLUSION
E cient and e ective processes are
needed for transitional care of older
adults with HF, with the goal of re-
ducing hospital readmissions. Ade-
quate self-care includes education and
management support. Home health
care nurses already see many patients
with HF and nurses and patients may
bene t from the CareNavRN special-
ized training. e CareNavRN nurse
has the advantage of developing a car-
ing and trusting relationship over time
with each patient during visits with
the patient and caregiver in the home
environment. Using the CareNavRN
intervention for older adults who do
not have access to a comprehensive
disease management program may
show promise to improve patient
quality care and health outcomes.
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40 Copyright © SLACK Incorporated
Table A
CareNavRN Intervention
Visit (time) Wee
k
Partici
p
ant Recruitment and Enrollmen
t
Hospital
Recruitment
by
Investigator
(30-45 min.)
1 -Potential participants identified from daily report from Quality Improvement
Department of patients with HF indicators (diagnosis, radiology, pro-BNP, diuretics),
then investigator review of EMR to determine if patients had HF diagnosis and met
inclusion criteria.
-Primary nurse provides study information Fact Sheet to potential participants
-Investigator meets with interested patients to discuss study; screens with Mini-Cog™;
obtains informed consent
-Patients randomized and CareNavRN nurse contacted for IG patients
-CG & IG baseline data collected: demographics, depression, functional status, health
literac
y
, and pre-intervention outcomes (HF knowled
g
e, self-care, & QOL)
CareNavRN Nurse Assessment Nurse Teaching Topic
from Education Booklet
Patient Tools from
Education Bookle
t
Hospital visit
by
CareNavRN
nurse
(30-60 min.)
1 -Review EMR, (medical history,
medication reconciliation, relevant
diagnostics, and discharge notes)
-Introduce, initiate rapport, provide
patient education booklet and begin
teaching
-Set up date/time for first home visit
within 24-72 hours
(Same CareNavRN nurse who
contacts patient in hospital will visit
p
atient at home)
-What is heart failure?
-Common symptoms of
HF
-Diagram of systolic
and diastolic HF
Home Visit 1
(within 24-72
hours of
hospital
discharge)
(60-90 min.)
1 Home environment assessment
-Available food items
-Fall risks, physical barriers/hazards
Family/social support assessment
-Referral needs
-Transportation
-Meals
Discussion of discharge plan of care
with patient & family caregiver*
Documentation of
-Weight; vital signs; heart & lung
sounds; edema*
-Skin/wounds; pain*
-Fatigue, dyspnea; exercise; mood*
-F/U apt; diet; fall risk*
-Medication changes and
management*
-Hospital or emergency department
visit since last visit*
-If worsening symptoms identified,
notification of provide
r
by
nurse*
-Medications to treat
HF & medication
management plan
-Low sodium diet and
fluid retention
-How to read labels &
kitchen inventory
-Worsening symptoms
and when to notify
provider
-Oxygen therapy (if
needed)
-Medication log
-Daily weight log
-List of high & low
sodium foods
-List of important
phone numbers
Home Visit
2
(45-60 min)
2 All of above (*) PLUS
-Check weight log & discuss
-Continued diet
education
-Tips to prevent
swellin
g
Daily food diary
Home Visit
3
(45-60 min)
3 All of above (*) PLUS
-Check weight and food logs and
discuss
-Introduce exercise and activity per
provider order
-Continued
reinforcement of topics
above
-Exercise and activity
per provider order
-Smoking cessation (if
needed)
Daily activity log
Home Visit
4
(45-60 min)
4 All of above (*) PLUS
-Review all topics
-Check weight, food, and activity
logs and discuss
-Address areas of concern
-Summarize progress
-Postintervention outcome data
collected (HF knowledge, self-care,
& QOL)
HF: Heart failure; EMR: Electronic medical record: CG: Control group; IG: Intervention group;
QOL: Quality of life; F/U: Follow-up
