Hain, Debra J.

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 purpose of this randomized control trial (RCT) was to investigate the effects
of a story-sharing intervention on older adults transitioning to long-term care (LTC). The
specific aims were (1) to determine the effects of story sharing on the health transition
outcomes of depression and well-being of adults transitioning to LTC; and (2) to
determine if the sociodemographic characteristics (age, gender, ethnicity, marital status,
level of education (LOE), months living at LTC facility, choice to move, and health
problem(s) that may have resulted in the move) predict depression and/or well-being.
Story sharing was defined as the respectful space where one tells and listens to stories of
others (Heliker, 2009) while being guided by another (the investigator). Meleis’ middlerange
theory of transitions (MMRTT) (Meleis et al., 2000) was used as a guide to
understand the transitioning process. A convenience sampling design was used to recruit
100 participants from 11 LTC facilities in Broward County, located in Southeast Florida. The sample included adults, age 65 years and older, who were transitioning to a
LTC facility within the past two years. Participants were randomly assigned to the control
group (n = 52), who received standard care, or to the intervention group (n = 41), who
received story-sharing and standard care.
The results indicated there was no significant greater improvement to suggest an
Intervention and Time effect for depression and/or well-being. Overall, predictive ability
of the sociodemographic variables for depression and well-being were not statistically
significant. However, LOE (junior college) did account for a significant portion of unique
variance for increased depression, and time, marital status, ethnicity, LOE, and choice to
move did account for a significant proportion of unique variance for well-being. Months
living in LTC (more months) and marital status (all but divorced) were significant for
improved well-being while ethnicity (Hispanic), LOE (high school and junior college),
and choice to move (no choice) were significant for reduced well-being. Similar studies
using a larger sample size, including non-English speaking participants; lengthier storysharing
sessions; and measuring for pain, health, and bereavement may offer additional
insights to healthy transition outcomes for this population.

Background. Adherence to the behavioral change component of the hemodialysis regimen is difficult for many reasons; when individuals fail to adhere, the nurses often become frustrated and individuals may be labeled nonadherent leading to inappropriate interventions. As the number of older adults starting hemodialysis increases, one contributing factor to nonadherence in this population may be cognitive impairment. Objective. The overall purpose of the study was to explore differences in global cognition, in self-report cognition, and in language ability relative to adherence in a sample of older adults undergoing hemodialysis. Methods. This pilot study examined the differences in cognition and adherence of older adults (≥60 years) undergoing out-patient hemodialysis three times a week for at least one year. Nonprobability purposive sampling was used to obtain a sample from multiple centers which offered a diverse sample of study participants (n=63). Stories of the challenges of making life style changes were audiotaped and analyzed with linguistic analysis and word count (LIWC) software and various standardized instruments that measure global cognition (3MS and MMSE), self-report cognition (KDQOL-CF) and language ability (COWA, subsets of BDAE Reading: Sentence and Paragraph and BDAE Complex Ideation) were administered during hemodialysis. Determination of adherence or nonadherence (based on literature) was completed as the last activity of data collection. Results. Statistical significance was not achieved when exploring the difference of global cognition, self-report cognition, and language ability relative to adherence (p > .05). A relationship between structural elements of big words, cognitive process and insight words used in story and measures of adherence was revealed (p < .05). Although statistical significance was not reached the descriptive data supports that a relationship between cognitive impairment and measures of adherence were present across groups. The majority (64%) of nonadherent participants had cognitive impairment; 34% of the middle group and 5% of the adherent group had cognitive impairment. Discussion. Cognitive impairment is prevalent among older adults undergoing hemodialysis, however a relationship between cognitive impairment and adherence was not revealed in this study. This may be the result of the small sample size and adherence markers that were not sensitive in this population. This preliminary work offered a descriptive foundation which generated more questions that may be answered with further research.