Essay: NP-driven self-care education: A solution to reduce 30-day heart failure readmissions

NP-driven self-care education: A solution to reduce 30-day heart failure readmissions
Heart failure is the most common chronic disease in the United States, affecting millions and costing billions. The reduction of hospitalizations for patients living with heart failure is a significant quality-measure goal, from both a quality of life and economic standpoint, and has become a national priority. In an effort to reduce 30-day heart failure readmissions, it is prudent to examine the current gaps in care, the APN role and theoretical framework, and how this unique role in health care may be able to address this national goal.
Heart Failure
Heart failure (HF) is defined as “a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.” (Yancy et al., 2013, p.1500). Individual clinical manifestations can vary, but typically involve dyspnea, fatigue, systemic and pulmonary congestion, and peripheral edema. These clinical manifestations result in exercise intolerance and an impairment of the individual’s ability to carry out activities of daily living. As heart failure progresses and cardiac function worsens, end-organ dysfunction significantly impacts morbidity and mortality. Heart failure is diagnosed based on a thorough assessment of the individual’s clinical manifestations of illness, and is classified by stages according to the American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) and New York Heart Association (NYHA) classes. While the ACCF/AHA stages emphasize disease progression, NYHA classes focus on describing exercise intolerance and symptomatic status of disease (Yancy et al., 2013).
Significance in US population
Approximately 5.7 million Americans have been diagnosed with HF, costing approximately $30.7 billion annually (Bergethon et al., 2016). For Americans over the age of 40, the lifetime risk for developing HF is 20%; the incidence is 20 per 1000 people over the age of 65 and 80 per 1000 for people over the age of 85. With an aging population, it is estimated that the number of people living with HF will increase significantly, to one in five of all Americans, by 2050 (Yancy et al, 2013).
Readmission Reduction
In the United States, HF is the leading cause of hospitalization for adults over 65 years of age. Over one million patients are hospitalized annually with a primary diagnosis of heart failure; approximately one in four are readmitted within thirty days of hospital discharge and over fifty percent are readmitted within six months of discharge (Yancy et al., 2013). Annual Medicare expenditure is over $17 billion on hospitalizations alone. In 2013, the Center for Medicaid and Medicare Services established the Readmissions Reductions Program (HRRP), which established a national quality goal to reduce readmission rates for patients with heart failure by at least 20%. CMS payments are reduced to hospitals with readmission rates that are higher than the 24% national average, thus incentivizing hospitals to improve on quality of care in the management of this chronic disease. While organizations and health care providers have worked hard to develop solutions to high readmission rates over the past several decades, readmission rates have not significantly been reduced (Yancy et al., 2013).
Current Trends/Gaps in Care
Hospitalization for the patient with HF is typically required when there are signs of decompensation, including: dyspnea at rest, hypoxia, hypotension, worsening end organ dysfunction, new onset arrhythmias, chest pain, electrolyte disturbances, associated concomitant medical conditions, or any new symptoms of HF in someone who was previously undiagnosed (HFSA, 2010). Physiological predictors for readmission include: elevated filling pressures, high cardiac biomarkers at the time of discharge, renal impairment or worsening renal status, and associated comorbidities (ACCF/AHA, 2013). With profound advances in technologies and the development of specialist roles in heart failure, many solutions to physiologic management of this chronic disease have been effective. However, it is important to consider disparities and challenges when considering the psychosocial factors that can impact patient outcomes as well. According to the AHA, “typical breakdowns following discharge from the hospital include: medication errors, patient lack of adherence to self-care, patient does not understand how to manage worsening symptoms, discharge instructions are confusing or not tailored to patient level of understanding, no follow up appointment, inability to keep appointment due to transportation, or not knowing who to contact if condition worsens” (AHA, 2017, p.2). No matter how advanced technologies or treatment options become, the inability to facilitate a seamless transition from hospital to home will continue to negatively impact patient outcomes, particularly for those who are most vulnerable and lack psychosocial support.
The APN Role
The advanced practice nurse, and more specifically the nurse practitioner (NP), has a unique role that has the potential to significantly improve patient outcomes if she is utilized efficiently. With core competencies that include direct patient care, guidance and coaching, consultation, evidence-based practice, leadership, collaboration, and ethical decision making, the APN is a cost-effective component of the interdisciplinary team who is capable of medical management of chronic disease as well as a key resource for individualized patient education and self-efficacy counseling (Hameric, Hanson, Tracy & O’Grady, 2014). With an emphasis on the competencies of direct patient care and evidence-based practice, the NP is highly capable of managing physiologic changes in the outpatient setting. Furthermore, the NP is skilled in collaboration, which becomes especially valuable for managing psychosocial needs, particularly for patients who may require multiple specialist providers, social workers, nutritionists, and home health services. If an NP is utilized as a primary contact person for the patient with heart failure, can her skills in disease management, self-efficacy consultation, collaborative communication, and accessibility help to reduce the chances of readmission? For the sake of this project, research will be aimed specifically at investigating the relationship between improved self-efficacy through NP-driven patient education and readmission rates.
Conceptual Framework
The utilization of Orem’s Self-Efficacy Deficit nursing theory helps to guide the development of a research question and interventions for the NP providing care. Orem’s theory is derived from the concept of self-care, which “is the performance or practice of activities that individuals initiate and perform on their own behalf to maintain life, health, and well-being” (George, 2011, p.115). When changes to an individual’s health status create an imbalance, being that self-care requisites exceed the individual’s self-care capabilities, Orem suggests this indicates the need for nursing. The development of a strong relationship between the NP and the patient provides the perfect foundation for assessing self-care deficits, and further supports the implementation of NP-driven education and interventions to address those requisites. According to Hameric, Hanson, Tracy, and O’Grady (2014), “the benefits of emphasizing self-care are supported by research showing that when patients are given information about illnesses and helped to manage their illness, such as heart failure, asthma, and arthritis, their courses of illness and quality of life are improved” (p.174).
Conclusion and Research Question
When examining the compounding physiological and psychosocial factors that impact the chances of readmission for patients with heart failure, the need for a strong presence of NP-driven care emerges as a potential solution.
The research question is as follows: can the implementation of an NP driven patient education program in the outpatient setting of an advanced heart failure clinic help to reduce 30-day readmission rates for patients with heart failure?