HOSPITALIZED HEART FAILURE PATIENTS

Transitional Care of Hospitalized Heart Failure Patients

ABSTRACT

In this study, we try to explore the concept of “Transitional Care” in a holistic context. The main focus of the research is on Transitional Care of Hospitalized Heart Failure Patients. The research also analyzes many aspects of transitional care of heart failure patients. A objective of this research is to evaluate the heart patients who receives transitional care services in hospital.

Table of Contents

ABSTRACTii

CHAPTER 1: INTRODUCTION1

Research Questions2

Hypothesis3

CHAPTER 2: LITERATURE REVIEW4

CHAPTER 3: MATERIALS AND METHODS7

CHAPTER 4: EXPECTED RESULTS AND CONCLUSION8

References9

CHAPTER 1: INTRODUCTION

Heart Failure (HF) remains a top primary admission diagnosis in the United States. The natural history of the disease process partially accounts for the readmissions we observe in our daily practice. Beyond a worsening disease state, patients and families are asked to become knowledgeable about HF and undergo lifestyle modifications in addition to their evidence based medical therapies. Numerous studies have demonstrated the importance of health education for this vulnerable population. In order to provide better quality care to our population and improved outcomes, we have designed a certification program for a local skilled nursing facility (SNF).

Heart Failure patients know as a high-risk chronically ill patient contributes significantly to the 30 day readmission rate for hospitalizations. According to (JAGS, 2004), “Although reports of randomized, controlled trails (RCTs) have yielded important information regarding the management of adults hospitalized for Heart Failure, little is known about the effectiveness of care management strategies for elders experiencing an acute episode of Heart Failure complicated by multiple other chronic conditions.” There have been 2 extensive research trails by Coleman, and Naylor that have tested multidisciplinary, register nurse directed, home base interventions specifically targeting hospitalized older patients with Heart Failure and co-existing chronic conditions. “Both trails demonstrated only short-term reductions in Heart Failure re-hospitalizations and no effect on readmission due to comorbid conditions”, (Jags, 2004).

Causes of high utilization and cost were contributed to: (Boutwell, A., Hwu, S., 2009).

Deviations from evidence-based care.

Poor communication among primary providers, specialists, health and community providers, and patients.

Lack of longitudinal management - care geared primarily toward acute episodes rather than long term stability.

Lack of an alternative to hospital admission.

Failure to identify change in patient condition early.

Failure to address patient's individual psychosocial issues.

Ineffective transition management post hospitalization.

In an effort to effectively and efficiently manage the ever growing Heart Failure (HF) patient population, the development of an evidence-based Heart Failure Program managed by a Heart Failure Resource Center is intended, The goal is to positively impact length of stay, 30-day readmissions, compliance with core measures, and coordinate an aligned approach utilizing time sensitive interventions, and follow-ups through a specific outpatient management plan.

Research suggests, “ that a multidimensional, individual approach targeting patients, and their care-givers, and emphasizing needs associated with the acute Heart Failure event, and coexisting conditions is the most clinically relevant, and potentially effective intervention,” (JAGS, 2004).

Research Questions

In a population of patients discharged from a Midwest community base hospital with primary diagnosis of Heart Failure, will the use of an individual ...