The Effect of a Heart Failure Nurse Navigator on 30-Day Hospital Readmissions of Older Adults

Across the US, 22% of Medicare patients hospitalized with a diagnosis of heart
failure (HF) will be readmitted within 30-days of discharge. There is no one costeffective
process identified to help patients transition home and maintain their own selfcare.
The aim of this study is to compare readmission rates, HF knowledge, self-care,
and quality of life for patients who transition home from the hospital under the care of a
Heart Failure Nurse Navigator (HFNN) with patients who receive usual care.
The HFNN is a home health RN with specialized training in HF care. The HFNN
visited intervention group (IG) participants once in the hospital, followed by weekly
home visits for one month. Control group (CG) participants received usual care,
consisting of discharge teaching by their primary nurse and follow-up with their primary
care provider (PCP) or cardiologist. Using a sequential mixed methods research design, this experimental randomized
controlled trial measured HF knowledge, HF self-care, and HF quality of life (QOL) at
enrollment and one month after discharge. Hospital readmissions and/or ED visits were
tracked in both groups. IG participants were interviewed using semi-structured
questions, findings of which were analyzed using conventional content analysis.
There were fewer all-cause hospital readmissions in the IG (3 of 19) than the CG
(6 of 21.) CG participants were 2.2 times more likely to be readmitted than the IG
participants. [x(1)=.935, p=.334 O.R.=2.2219]. Due to limited enrollment, these results
were underpowered and not statistically significant. There was improvement in HF
knowledge (p=.06) and HF self-care maintenance (p=.07), approaching significance. HF
self-care maintenance improved in both groups, although the IG was not significantly
better (p=.48). There was significant improvement in the IG for HF confidence (p=.002)
and HF QOL (p<.001).
The qualitative findings revealed two main categories from the IG: (1) personal
clarification of patient education, especially related to diet, exercise, and medications and
(2) feelings of support, reassurance, and safety. The HFNN may be one role to meet the
triple aim of improving patient quality care and health outcomes at a reduced cost,
especially in areas where a comprehensive HF management program is not available.