There are more than 6.2 million adults in the United States with heart failure (HF), with projected growth to >8 million by 2030, including a substantial increase in HF incidence and prevalence in older adults (Benjamin et al., 2019). Despite improvements in guideline-directed therapy for HF, it remains a frequent reason for hospitalization of older adults (Jalnapurkar et al., 2018). From 2001 to 2014, 75.3% of all adults hospitalized with a primary or secondary diagnosis of HF were age ≥65 (Akintoye et al., 2017).
Care transitions and unplanned re-admissions have been at the forefront of health policy discussions since 2009 when a retrospective analysis of >11 million Medicare beneficiaries revealed that approximately 20% were readmitted within 30 days of hospital discharge (Jencks, Williams, & Coleman, 2009). HF is the most frequent diagnosis linked to 30-day readmissions; between 20% and 25% of patients discharged with HF will return to the hospital within 30 days (Jalnapurkar et al., 2018). Readmission risk for patients with HF increases each year after age 55 (Whellan et al., 2016). Although the United States' Healthcare Readmission Reduction Program (HRRP) legislation has demonstrated some success in reducing HF readmissions, it has also been associated with an alarming increase in HF mortality (Gupta et al., 2018). The HRRP may have incentivized hospitals to discharge patients in a way that might actually decrease their survival, which is an important reason to determine the best strategy for older adults transitioning from the hospital to home (Gupta et al., 2018).
Successful transition to home with HF involves self-care activities, such as medication management, diet and weight monitoring, exercise, attention to worsening symptoms, and knowledge of when to contact a health care provider (Riegel, Dickson, & Faulkner, 2016). Although this information is included in standard discharge education, older adults may have difficulty understanding the disease process (i.e., HF knowledge) and adapting to new dietary and medication regimens (i.e., HF self-care) as they transition home (Hain, Tappen, Diaz, & Ouslander, 2012; Riegel et al., 2016). In addition, the stress of hospitalization, including sleep deprivation, physical deconditioning, and nutritional deficit, contributes to the generalized vulnerability of older adults who are recently discharged (Krumholz, 2013).
Recognizing that ineffective transitions are a risk factor for 30-day HF readmissions in older adults, many researchers have focused their interventions on the transition process. Studies have demonstrated some improvement in outcomes, but all with limitations. One challenge has been hospital staff nurse time for discharge education (Albert et al., 2015). Even though discharge teaching can help reduce the risk for 30-day readmission (Kommuri, Johnson, & Koelling, 2012), most hospital nurses spend no more than 5 to 15 minutes on this important task (Albert et al., 2015).
Alternatively, some researchers have sought to address HF readmissions through telephone follow up or telemonitoring, with mixed results. In one study, post-discharge telephone calls by lay navigators only slightly reduced readmissions in older adults (Balaban et al., 2015); in another study, a combination of health coaching telephone calls with telemonitoring yielded no significant difference in readmissions (Ong et al., 2016); and a systematic review and meta-analysis of HF telemonitoring randomized controlled trials (RCTs) revealed no reduction in all-cause readmissions (Inglis, Clark, Dierckx, Prieto-Merino, & Cleland, 2015). These findings support the need for a different approach to this complex issue, such as face-to-face relational connection with older adults transitioning home with HF.
The importance of a face-to-face connection was highlighted in several systematic reviews of HF transitional care interventions with older adults (Van Spall et al., 2017; Verhaegh et al., 2014). One of the most important aspects that led to improved clinical outcomes (i.e., decreased 30-day readmissions) was the individual post-discharge support that reinforced self-care (Van Spall et al., 2017). Some studies have provided this support by combining multidisciplinary discharge education with home visits, and although promising, it has been difficult to determine the critical elements of the intervention (Stamp, Machado, & Allen, 2014; Vedel & Khanassov, 2015). Several studies on HF transitional care have demonstrated that nurse-driven transitional programs, with at least weekly contact, were one of the best ways to reduce 30-day readmission (Van Spall et al., 2017; Verhaegh et al., 2014). Advanced practice nurses (APNs) who received extensive geriatric training and made frequent home visits over 3 months markedly decreased readmissions of older adults at 1 year, but the program cost was approximately double that of routine home care (Naylor et al., 2004).
Educating home health RNs in the specialized care of older adults who are transitioning home with HF may be an effective strategy to improve self-care and reduce 30-day readmissions. Experienced home health nurses have a particular skill set and comfort level to assess and educate patients in their own environment; these elements could be especially useful for transitioning recently discharged older adults with HF. With additional education and training in HF management, home health nurses may be the answer, yet there is lack of evidence to support this potentially cost-effective approach. In response to this need, the current investigator developed an intervention (CareNavRN™) for home health nurses to receive specialized HF education and visit a sample of older adult patients before and after hospital discharge. The purpose of the current study was to examine the effect of the CareNavRN intervention on 30-day hospital readmissions, HF knowledge, HF self-care, and HF quality of life (QOL) in older adults (i.e., age ≥65 years) with HF.
The current study was a RCT of 40 older adults recruited from a 400-bed not-for-profit hospital in the southeastern United States. Each participant had a primary or secondary diagnosis of HF and was randomized into an intervention (n = 19) or control (n = 21) group. Initially, 76 patients were planned with 38 in each group (p = 0.05; power = 80; odds ratio = 2.12). Due to recruitment challenges and potential influence of a larger competing study with the same population, the sample was limited to 40. The hospital research committee and the researcher's university Institutional Review Board approved the study protocols.
Potential participants were identified from a daily report generated by the hospital's Quality Improvement Department, which tracked patients with indicators of high readmission risk diagnoses. For patients with HF indicators (e.g., elevated pro-B-type natriuretic peptide, radiology reports, diuretic medications), the electronic medical record (EMR) was reviewed by the investigator for a HF diagnosis. Inclusion criteria for the current study were: (a) score ≥3 on the Mini-CogTM, a three-item word-learning and recall task with a clock-drawing distractor before word recall (Borson, Scanlan, Chen, & Ganguli, 2003); (b) age ≥65; (c) a primary or secondary diagnosis of HF; and (d) residence within 20 miles of the hospital for at least 30 days after discharge. Patients unable to participate in pre-/post-testing (i.e., those who were non-English-speaking, had severe and uncorrected hearing loss, or dementia) were excluded. Informed written consent was obtained, and patients were randomly assigned to the intervention or control group using a random number table. The group assignment was not known until after consent and randomization.
RNs who delivered the intervention were invited from the staff of the hospital's home health department. These nurses had an interest in cardiology and at least 2 years of experience in home health. Six nurses volunteered for the study and all attended 6 hours of HF education based on the Heart Failure Nursing Certification Core Curriculum Review (Paul & Kirkwood, 2015) taught by the investigator, who is a certified HF nurse. They were trained in the CareNavRN study protocol and instrumentation.
Patients in the intervention group received one visit in the hospital by the CareNavRN nurse followed by four visits by that same nurse over 30 days post-discharge (Table A, available in the online version of this article). The intention of using the same nurse was to facilitate rapport and develop the nurse/patient relationship. In most cases, each nurse made the initial visit in the hospital to meet the patient and provide a HF education booklet. If study enrollment occurred on discharge day before the home health nurse was able to get to the hospital, she then called the patient before discharge (n = 4). If the patient was cognitively impaired and a cohabiting family caregiver was interested in participating in the study, Mini-Cog and informed consent was obtained from the caregiver and education was provided to the patient and caregiver (n = 2). All patients were visited at home within 72 hours of discharge, with most being seen within 24 hours of discharge. A home visit within 3 days is one component of care shown to decrease 30-day read-mission rates (Verhaegh et al., 2014).
The CareNavRN nurse provided HF teaching, including pathophysiology, symptoms, and medications, according to a teaching plan that accompanied a patient education booklet. During each home visit, the nurse performed a physical assessment, examined the home environment, and talked with the patient about how he/she was assimilating the HF discharge instructions into daily life (Table A). The investigator, who accompanied each CareNavRN nurse on at least one home visit, assessed fidelity to the study protocol.
The control group received usual care, which comprised printed and verbal HF discharge education delivered by the primary hospital RN. The intervention and control groups received home health care, as is usual for patients with a HF diagnosis. In addition, the intervention group received the CareNavRN intervention.
During the initial hospital contact, the investigator obtained informed consent, collected baseline data, and reviewed the EMR. Health indicators measured to ensure comparability of groups at baseline included the variables of depression (Geriatric Depression Scale-15; Sheikh & Yesavage, 1986), functional status (Lawton Activities of Daily Living Scale; Graf, 2008), and health literacy (Newest Vital Sign; Weiss et al., 2005). The CORE calculator, a statistical model developed from chart data abstraction (Yale-New Haven Hospital Center for Outcomes Research and Evaluation, 2012), measured readmission risk.
The primary outcome of 30-day hospital readmission post-discharge was determined by patient self-report at each visit for the intervention group and with a post-survey for the control group. Self-report for both groups was validated by EMR review. Secondary outcomes of HF knowledge, self-care, and QOL were measured at enrollment and 30 days post-discharge. The Dutch HF Knowledge Scale, a widely used 15-item multiple-choice questionnaire on HF physiology, measured HF knowledge and management. This scale has a reported Cronbach's alpha of 0.62 (van der Wal, Jaarsma, Moser, & van Veldhuisen, 2005).
Self-care was measured by the Self-Care of HF Index (SCHFI) v.6.2, a 22-item, 4-point Likert scale measuring the three self-care components of maintenance, management, and confidence (Riegel, Lee, Dickson, & Carlson, 2009). Of 100 possible points, a score ≥70 on each scale is considered adequate self-care. The HF maintenance scale (alpha = 0.55) helps evaluate a patient's daily activities to prevent worsening symptoms, such as diet, medication adherence, and monitoring of weight and edema. The HF management scale (alpha = 0.60) measures a patient's response to worsening symptoms, such as difficulty breathing or edema. The HF confidence scale (alpha = 0.82) registers a patient's perceived ability to remain symptom-free, follow treatment advice, recognize changes, and respond promptly (Riegel et al., 2009). As the SCHFI includes several dimensions of self-care, Cronbach's alpha may not be the best measure of internal consistency. In later testing, exploratory factor analysis identified sub-dimensions and confirmatory factor analysis indicated an excellent fit in all three scales (Vellone et al., 2013).
QOL was measured by the Minnesota Living with HF Questionnaire, a 21-item, 6-point Likert scale. This scale measures the physical, psychological, and social impact of HF, with reported Cronbach alphas >0.80 for all scale items (Heo, Moser, Riegel, Hall, & Chrisman, 2005).
To assess any potential differences between the intervention and control groups on demographic characteristics, chi-square tests were conducted on categorical sociodemographic and clinical variables. Likewise, to assess any potential differences at baseline between these groups on the outcome variables (i.e., HF knowledge, self-care, and QOL), independent sample t tests were used. To test the effectiveness of the CareNavRN intervention on the reduction of 30-day hospital readmission rates between the intervention and control groups, a chi-square test was used, as the outcome was a 2×2 contingency (Field, 2018).
The overall effectiveness of the CareNavRN intervention over time was assessed using a repeated measures analysis of variance (ANOVA) for measures of HF knowledge, three constructs of HF self-care, and HF QOL while controlling for individual differences. Repeated measures ANOVA is the most appropriate test because it controls for the dependence of measurement when tests are repeated over time (Stevens, 2009). Family-wise adjustments were used for the self-care scales.
There were no significant differences in baseline demographics, clinical characteristics, calculated readmission risk, or baseline outcome measures for the two groups (Table 1). Mean participant age was 82.7 years (SD = 8.27 years), 52.5% were male, and 97.5% were White/non-Hispanic. Most patients had a primary diagnosis (65%) as well as a history (63%) of HF. One patient in the intervention group dropped out after the first in-hospital CareNavRN visit, citing stress of her hospital course. Although the patient was not readmitted, she did not receive any home visits and was excluded from analysis.
Categorical Variables by Treatment Group (N = 40)
Hospital readmissions within 30 days occurred in six (29%) patients in the control group and three (16%) patients in the intervention group, although results were underpowered and non-significant. HF knowledge improved significantly over time in the intervention group (p = 0.043). Self-care maintenance (p = 0.071) and management (p = 0.480) improved over time in both groups. HF self-care confidence improved significantly over time in the intervention group (p = 0.003). HF QOL demonstrated significant improvement over time in the intervention group (p < 0.001) (Table 2). Of the three variables that improved over time, only QOL significantly predicted readmission likelihood in both groups, irrespective of intervention (χ2 = 3.86, p = 0.049, Nagelkerke R2 = 0.17].
Control and Intervention Group Change Over Time for Heart Failure (HF) Knowledge, Self-Care, and Quality of Life
A post-hoc analysis was conducted to assess for outcome differences related to timing of the first home visit (within 24 hours vs. 24 to 72 hours). Four patients who received a telephone call versus meeting the Care-NavRN nurse in the hospital were also analyzed post-hoc. There was no significant difference in readmissions (χ2 = 0.18, p = 0.671) or any significant difference in change over time for other outcomes regarding home visit timing (p = 0.555 to 0.845) or hospital visit/telephone call (p = 0.446 to 0.885).
There were only one half as many readmissions in the intervention group compared to the control group. It was originally hypothesized that improvement over time in the secondary outcomes related to the intervention would also result in fewer readmissions. Unfortunately, the study was underpowered, and the results were non-significant. This intervention may provide an approach to decrease readmissions in older adults with HF, although further testing with greater numbers of participants should be conducted before program initiation.
The CareNavRN intervention uniquely combines three components that have individually demonstrated effectiveness in reducing readmissions in prior studies. The first component is the face-to-face relational interaction between the health care provider and patient, which has demonstrated decreased hospital readmissions in other HF studies (Van Spall et al., 2017). Secondly, home visits are an effective way to assess implementation of discharge instructions (Stamp et al., 2014; Verhaegh et al., 2014). Weekly patient contact is the third component of the CareNavRN intervention. This was supported by a recent review of interventions to prevent readmissions, which indicated that potential patient challenges must be assessed prior to discharge and that transitional care programs should include some type of weekly follow-up contact (Ziaeian & Fonarow, 2016).
Heart Failure Knowledge
The current results indicated significant improvement in change over time for HF knowledge in the intervention group compared to the control group. Knowledge deficit continues to be a problem in many patients hospitalized with HF. Only 10% of patients discharged from a hospital with a high-volume disease management program understood all six discharge educational topics required by The Joint Commission (Regalbuto, Maurer, Chapel, Mendez, & Shaffer, 2014). A comprehensive understanding of HF signs and symptoms has been associated with improved self-care (Lee, Moser, & Dracup, 2018). In the CareNavRN intervention, patients not only received instructions prior to discharge, but also received reinforcement and additional instruction in the subsequent four home visits.
The CareNavRN intervention demonstrated statistically significant improvement in change over time for HF self-care confidence in the intervention group compared to the control group. Adequate or improved self-care confidence is associated with improving day-to-day self-care maintenance (Pancani et al., 2018). Self-care confidence in older adults is an important mediator between cognition and self-care (Vellone et al., 2015). Patients with adequate cognition may not be successful in self-care due to low confidence, whereas those with higher confidence may achieve adequate self-care, even if cognitively impaired (Vellone et al., 2015). This finding underscores the importance of confidence in self-care activities. Addressing concerns on an individual basis with a compassionate, caring, and knowledgeable professional, who can formulate self-care solutions, may help boost confidence in a person transitioning home with HF.
Home health nurses with specialized HF training were used in the CareNavRN study and most of the patient education and support took place in the home. The CareNavRN intervention demonstrated similar self-care results as other studies using APNs (Graven, Gordon, Keltner, Abbott, & Bahorski, 2018) or RNs (Dalal et al., 2019; Van Spall et al., 2017). The current findings indicate that placing more emphasis on the home visit can make a difference in self-care confidence.
Quality of Life
The QOL results in the intervention group were perhaps the most striking findings of the current study. The average score of patients in the control group indicated a significant worsening of their QOL over time (i.e., higher scores indicate worsening QOL). It was surprising that the control group's scores would decline to such a degree. Conversely, the average score of patients in the intervention group indicated a significant positive change over time associated with the CareNavRN intervention. In other studies on QOL during HF transitions, control and intervention groups experienced a generally positive effect on QOL (Stamp et al., 2014; Wang, Dong, Jian, & Tang, 2017). Patients who have relational support (such as that provided by CareNavRN nurses) and understand their medications, dietary instructions, and exercise recommendations may be more likely to believe that they can manage this health challenge and experience improved QOL (Rice, Say, & Betihavas, 2018).
Practice and Research Implications
The challenge of HF readmissions in older adults is multifaceted. Coordinating care from hospital to home involves improving communication between the provider and patient, education of the patient and caregivers, and monitoring of the patient in the home environment. The supportive nurse/patient relationship found in the CareNavRN intervention may be able to bridge this gap for older adults. This intervention can help patients become confident in self-care and understand what to do when symptoms worsen. If the CareNavRN role was to become standard practice for home health HF care, geriatric clinicians might refer appropriate patients to this specialized program. Referral to this program would be especially important for older adults if there are no local HF management programs or if transportation is a barrier to their participation.
Repeating this study with more patients over a longer follow-up period (6 to 18 months) is needed to determine lasting effects of the CareNavRN approach. Specifically for readmissions, type II error could be avoided by increasing the number of participants and thereby increasing statistical power. Implementing the CareNavRN intervention with a more diverse population would yield more generalizable results. The addition of an attention control group may help elucidate which components of the intervention were most effective for older adults with HF. It would also be helpful to examine the QOL outcome in light of the changes observed in the intervention and control groups. Further analysis of the impact of meeting the CareNavRN nurse in the hospital is also warranted, as there was no significant difference in the outcomes for the four patients who received a telephone call and those who received a visit.
The CareNavRN study was a small, single-center RCT with a homogeneous patient population, which along with other variables, such as the time spent in usual care discharge teaching for the control group, could not be controlled and consequently limits generalizability. There was no attention control group, so the results may be due to the time the CareNavRN nurse spent with the patient and not necessarily the intervention itself. The previously mentioned recruitment challenges and competing study limited participants to 40, and as a result, the study was underpowered. A larger sample may have demonstrated statistical significance for self-care maintenance and readmissions. Regardless, it is important to note any decrease in readmissions, and the potential benefits of the nurse/patient relationship in the CareNavRN intervention invites further research.
Efficient and effective processes are needed for transitional care of older adults with HF, with the goal of reducing hospital readmissions. Adequate self-care includes education and management support. Home health care nurses already see many patients with HF and nurses and patients may benefit from the CareNavRN specialized training. The CareNavRN nurse has the advantage of developing a caring and trusting relationship over time with each patient during visits with the patient and caregiver in the home environment. Using the CareNavRN intervention for older adults who do not have access to a comprehensive disease management program may show promise to improve patient quality care and health outcomes.
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Categorical Variables by Treatment Group (N = 40)
|Variable||Control Group (n, %) (n = 21)||Intervention Group (n, %) (n = 19)||p Value|
| Female||10 (47.6)||9 (47.4)|
| Male||11 (52.4)||10 (52.6)|
| White/non-Hispanic||21 (100)||18 (97.5)|
| White/Hispanic||0||1 (2.5)|
| Some high school||2 (9.5)||0|
| Graduated high school||5 (23.8)||4 (21.1)|
| Some college||6 (28.6)||5 (26.3)|
| Graduated college||4 (19)||7 (36.8)|
| Master's degree||2 (9.5)||2 (10.5)|
| Doctorate degree||2 (9.5)||1 (5.3)|
| Married||12 (57.1)||9 (47.4)|
| Widowed||6 (28.6)||7 (36.8)|
| Divorced||2 (9.5)||3 (15.8)|
| Single/never married||1 (4.8)||0|
| Spouse||10 (47.6)||8 (42.1)|
| Alone||6 (28.6)||9 (47.4)|
| Children||2 (9.5)||2 (10.5)|
| Significant other||1 (4.8)||0|
| Other family member||1 (4.8)||0|
| Friends||1 (4.8)||0|
|Hospital LOS (days)||0.830|
| 1 to 3||8 (38.1)||6 (31.6)|
| 4 to 5||10 (47.6)||8 (42.2)|
| 6 to 10||2 (9.6)||3 (15.8)|
| 11 to 20||1 (4.8)||2 (10.5)|
| No||19 (90.5)||18 (94.7)|
| Yes||2 (9.5)||1 (5.3)|
| Primary||12 (57.1)||13 (68.4)||0.721|
| Secondary||9 (42.9)||6 (31.6)||0.945|
|History of HF||0.307|
| Yes||12 (57.1)||13 (68.4)|
| No||9 (42.9)||6 (31.6)|
| No (0 to 5)||16 (76.1)||16 (84.2)|
| Suggested (>5)||4 (19)||3 (15.8)|
| Yes (>10)||1 (4.8)||0|
|Functional status (score)b||0.208|
| Low (1 to 3)||5 (23.8)||2 (10.6)|
| Moderate (4 to 6)||1 (4.8)||4 (21)|
| High (7 to 8)||15 (71.4)||13 (68.5)|
|Health literacy (score)c||0.322|
| Likely limited (0 to 1)||2 (9.5)||0|
| Possibly limited (2 to 3)||2 (9.5)||1 (5.3)|
| Adequate (4 to 6)||17 (81)||18 (94.7)|
|Ejection fraction (%)||0.513|
| 15 to 19||0||2 (10.5)|
| 20 to 29||4 (19)||1 (5.3)|
| 30 to 39||2 (9.5)||1 (5.3)|
| 40 to 49||2 (9.5)||3 (15.8)|
| 50 to 59||9 (42.9)||9 (47.3)|
| 60 to 69||3 (14.3)||3 (15.8)|
| 70 to 79||1 (4.8)||0|
|Calculated readmission risk (%)||22.7 (4.5)||22.9 (4.7)||0.901|
Control and Intervention Group Change Over Time for Heart Failure (HF) Knowledge, Self-Care, and Quality of Life
|Variable||Mean (SD)||F(1,33)||p Value||η2|
|Control Group||Intervention Group|
|Dutch HF Knowledge Scalea||10.71 (2.09)||11.76 (1.86)||11.33 (1.78)||13.44 (1.54)||3.13||0.043||0.09|
| Maintenance||61.96 (14.72)||71.95 (17.16)||60.01 (14.99)||77.03 (14.81)||2.27||0.071||0.06|
| Management||34.41 (17.04)||48.12 (20.93)||42.50 (13.53)||53.14 (19.02)||0.00||0.480||0.00|
| Confidence||62.13 (24.48)||62.82 (23.67)||56.84 (15.32)||83.38 (15.36)||10.69||0.003||0.25|
|Minnesota Living With HF Questionnairec||44.65 (17.72)||55.12 (26.66)||58.39 (17.15)||28.94 (18.08)||38.63||<0.001||0.54|
|Visit (time)||Week||Participant Recruitment and Enrollment|
|Hospital Recruitment by Investigator (30–45 min.)||1|
Potential participants identified from daily report from Quality Improvement Department of patients with HF indicators (diagnosis, radiology, pro-BNP, diuretics), then investigator review of EMR to determine if patients had HF diagnosis and met inclusion criteria.
Primary nurse provides study information Fact Sheet to potential participants
Investigator meets with interested patients to discuss study; screens with Mini-CogTM; obtains informed consent
Patients randomized and CareNavRN nurse contacted for IG patients
CG & IG baseline data collected: demographics, depression, functional status, health literacy, and pre-intervention outcomes (HF knowledge, self-care, & QOL)
|CareNavRN Nurse Assessment||Nurse Teaching Topic from Education Booklet||Patient Tools from Education Booklet|
|Hospital visit by CareNavRN nurse (30–60 min.)||1|
Review EMR, (medical history, medication reconciliation, relevant diagnostics, and discharge notes)
Introduce, initiate rapport, provide patient education booklet and begin teaching
Set up date/time for first home visit within 24–72 hours
(Same CareNavRN nurse who contacts patient in hospital will visit patient at home)
What is heart failure?
Common symptoms of HF
Diagram of systolic and diastolic HF
|Home Visit 1 (within 24–72 hours of hospital discharge) (60–90 min.)||1||Home environment assessment
Family/social support assessment
Available food items
Fall risks, physical barriers/hazards
Discussion of discharge plan of care with patient & family caregiver*
Weight; vital signs; heart & lung sounds; edema*
Fatigue, dyspnea; exercise; mood*
F/U apt; diet; fall risk*
Medication changes and management*
Hospital or emergency department visit since last visit*
If worsening symptoms identified, notification of provider by nurse*
Medications to treat HF & medication management plan
Low sodium diet and fluid retention
How to read labels & kitchen inventory
Worsening symptoms and when to notify provider
Oxygen therapy (if needed)
Daily weight log
List of high & low sodium foods
List of important phone numbers
|Home Visit 2 (45–60 min)||2||All of above (*) PLUS
Check weight log & discuss
Continued diet education
Tips to prevent swelling
|Daily food diary|
|Home Visit 3 (45–60 min)||3||All of above (*) PLUS
Check weight and food logs and discuss
Introduce exercise and activity per provider order
Continued reinforcement of topics above
Exercise and activity per provider order
Smoking cessation (if needed)
|Daily activity log|
|Home Visit 4 (45–60 min)||4||All of above (*) PLUS
Review all topics
Check weight, food, and activity logs and discuss
Address areas of concern
Postintervention outcome data collected (HF knowledge, self-care, & QOL)