Leavitt, Mary Ann M.

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.

The aim of this study is to compare readmission rates for patients who transition home from the hospital
under the care of the Heart Failure Nurse Navigator (HFNN) with patients who receive usual home
health care. Heart failure (HF) accounts for 20% of all hospital admissions and is the most common
diagnosis associated with a 30-day readmission of Medicare patients. Nationally, 24.7% of patients
with HF are readmitted within 30 days. The AHA and ACCF recognize a critical need for evidence
identifying best processes of care in transition from hospital to home. The comprehensive NN role not
only teaches the patient to adapt to the prescribed medical protocol, but also provides connectedness
and relationship. Home health nurses taught to perform the role of a HFNN may improve coordination
of post-hospital care and patient outcomes. The research design will be sequential mixedmethod.
Phase I will be a quantitative, quasi-experimental randomized study of the effect of HFNN on
30-day readmissions. Pre- and post-testing for HF self-care knowledge and quality-of-life will be
analyzed by repeated ANOVA. Independent T-tests will compare readmission rates between groups.
Phase II will be a qualitative study of transitioning home under the care of the HFNN. Intervention
patients will be invited to focus groups, and their responses to semi-structured questions will be coded
using conventional content analysis. It is hoped that the quantitative portion of the study will
demonstrate that the HFNN intervention will keep more patients out of the hospital for at least 30 days
and improve the HF self-care knowledge and quality of life. The qualitative portion may uncover
unknown elements of the HFNN/patient dynamic, as well as themes helpful in formulating further
questions about care of the patient with HF.