S

Transitions of Care in
Heart Failure Patients
Dana Lawrence
Problem Statement

S Elderly patients with heart failure often experience
ineffective transitions of care from the hospital setting into
the community
Background
S 5.7 million adults are affected by heart failure in the
United States ( Creber, Allison, and Riegel, 2013).
S An integral part of management with this patient
population is transitions of care
S Transitions of care is defined as the movement of
patients between healthcare practitioners, settings and
home as the condition and care needs change. (The
Joint Commission, 2012).
Background
S Contributing factors to poor transitions in care congruent with
nursing practice(TJC, 2012):
S Insufficient or late discharge planning
S Failure to identify patient limitations early enough or at all before
discharge
S Inadequate education from caregivers to patients/ families
S Leads to noncompliance
S Ineffective communication between caregivers in different
settings
S Nurses not taking ownership
S Lack of teamwork and respect



Significance
S
S Naylor (2004), attests that among all rehospitalizations,
older adults with heart failure have the highest rates.
S Hospital admissions increases chances of cardiac events
and sentinel events, decreasing quality of life (Bethihavas,
et al., 2013)
S Heart failure is the primary cause of hospital admissions
among Medicare patients (Creber et. Al, 2013).
S In 2010, it was estimated that most of the costs associated
with heart failure would be due to hospitalizations and
would exceed $39.2 billion dollars (Creber et al., 2013).

Nursing Role
S The nurse plays a key role in educating and empowering the patient/ family for
discharge and in general.
S Effective self- care management and maintenance education( by the nurse) for elderly
patients with congestive heart failure is imperative to improve quality of life and
decrease hospital admissions. (Veroff et al., 2012)
S Communication between nurses in the hospital setting and in the community setting
is very relevant among the elderly as more of them are required to a sub-acute
setting or home with home healthcare.





Alternative Solutions
S Assess risks and limits for patients upon and throughout admissions (TJC, 2010).
S Assess for factors that will limit patient/ family from following discharge instructions ie. Recent admission,
illiterate.
S Follow up after discharge
S Hospitals who had nurse leaders call and follow up with patients were able to answer questions, ensure follow
up with primary care providers and therefore decreased admissions
S The nurse leader can advocate for the use of a transition of care model
S Ie. Care Transitions Intervention, Transitional Care Model, The Bridge Model
S Participation in standardized hand off tools to ensure accurate communication between healthcare
settings.

S Pilot studies show that institutions utilizing specific hand- off tools produced measurable improvement in the
ability to effectively care for patients as they transition from one care setting to another (TJC, 2010, p. 6).
S Accountability- sharing names, contact numbers during hand off.


Implementation of Transition of
Care Model
S Multi-disciplinary communication, collaboration and coordination (TJC, 2010, p. 5).
S The nurse is in the position to link communication between all disciplines because he/
is has the most constant assessment of the patient.
S Actively teaching patients and family, reinforcing education from other disciplines
S Shared accountability
S Sharing name and contact information of sender and receiver
S Risk Assessment
S Implement within 48 hours of admission
S Follow-up
S Case manager or nurse leader to call patients within 3 days of discharge to verify
follow up appointments and answer appropriate questions



Evaluation
S Ultimate goal: Decrease readmissions (Systems level)
S Evaluation of effective/early discharge planning will ultimately
result in less readmissions to the hospital
S Surveys from patients and families to evaluate the their
satisfaction with transitions and understanding of plan of care.
S Evaluation of proper hand- off communication
S Use the Targeted Solutions Tool for Hand-off Communication
which evaluates communication between settings (TJC, 2010).
References
S Betihavas, V., Newton, P. J., Frost, S. A., Macdonald, P. S., & Davidson, P. M. (2013). Patient, provider and system factors
influencing hospitalization in adults with heart failure. Contemporary Nurse: A Journal for The Australian Nursing Profession,
43(2), 244-256. doi:10.5172/conu.2013.43.2.244
S Creber, R., Allison, P. D., & Riegel, B. (2013). Overall perceived health predicts risk of hospitalizations and death in adults with
heart failure: A prospective longitudinal study. International Journal Of Nursing Studies, 50(5), 671-677.
S The Joint Commission. (2012 ) Transitions of care: The need for more effective approach to continuing patient care. Retrieved
from http://www.jointcommission.org/assets/1/18/Hot_Topics-Transitions_of_Care.pdf
S Naylor, M., Brooten, D., Campbell, R., Maislin, G., McCauley, K., & Schwartz, J. (0001).
S Transitional care of older adults hospitalized with heart failure: A Randomized, controlled trial (English). Journal Of The
American Geriatrics Society, 52(5), 675-684.
S Veroff, D. R., Sullivan, L. A., Shoptaw, E. J., Venator, B., Ochoa-Arvelo, T., Baxter, J. R., & ... Wennberg, D. (2012). Improving
Self-Care for Heart Failure for Seniors: The Impact of video and written education and decision aids. Population Health
Management, 15(1), 37-45. doi:10.1089/pop.2011.0019