Managing Heart Failure in Long-term Care

More than six million people in the United States have heart failure (HF), and a substantial number of these individuals are hospitalized at some point in their lifetime.¹ Many even experience multiple hospital admissions.¹ In 2012, the costs associated with HF management exceeded $5 billion.² These costs are expected to increase in the future as the population ages.² The prevalence of HF increases with age, and approximately 85% of HF cases occur in individuals over 65 years of age. HF is the principle diagnosis for Medicare recipients.³

There is no cure for HF, and the progressive nature of the disease requires effective disease management. Disease management is challenging due to exacerbations, complicated treatment regimens, and hospitalizations. Elderly patients pose additional difficulties in disease management due to multiple comorbidities, cognitive issues, and lack of social support.⁴

Many elderly patients with HF who are hospitalized require discharge to transitional care prior to returning home; such transitional care may be provided in nursing homes, in inpatient rehabilitation facilities, or through home health services.⁵ Over the last decade, long-term care (LTC) facilities have evolved into post-acute care centers, providing transitional care for patients with HF after hospitalizations. Approximately 40% of Medicare beneficiaries are discharged to post-acute care; approximately half of these individuals enter LTC or skilled care settings.⁵ Many facilities provide post-acute or skilled nursing services and traditional tertiary care within the same building. Interventions to Reduce Acute Care Transfers (INTERACT; www.interact2.net) is a quality improvement program supported by the Centers for Medicare & Medicaid Services (CMS) that focuses on the management of acute change in condition. INTERACT provides facilities with tools to improve care and reduce transfer to the hospital from LTC, assisted living, and home health.

Effective disease management practices within LTC facilities are important to effectively manage HF. Reviewing 2004 Medicare data, almost 20% of patients discharged for skilled nursing services were readmitted to the hospital within 30 days.^5,6 These readmissions are financially burdensome to the health care system and emotionally difficult for patients and caregivers.^1,7 Many of these rehospitalizations are preventable.⁸ CMS identified that hospital readmissions contribute to excess health care costs and, as a cost-saving measure, implemented the Hospital Readmissions Reduction Program, which financially penalizes hospitals with excess readmissions.² Acute care settings now have a financial stake in post-acute care because readmissions can have a negative effect on reimbursement.

To reduce the revolving door of readmissions, improve patient outcomes, and reduce financial burden, evidence-based practice (EBP) standards must be incorporated into management of HF within the LTC setting. Therefore, the purpose of this integrative review is to compile best practices for the management of HF in LTC settings. The incorporation of evidence-based care, using a systematic approach for assessment and recognition of symptoms, can prevent rehospitalization and improve outcomes of patients discharged for skilled nursing services prior to transitioning home.^9,10 EBP can also improve disease management and reduce transfer of fragile older residents from LTC facilities.¹⁰

Literature Search and Selection

A literature review was conducted that included searches of the following databases: CINAHL, Proquest Nursing and Allied Health Science, Medline, and Health Source: Nursing/Academic Edition. Searches were done using the terms “heart failure” or “congestive heart failure” and “skill* nurs* facil*” or “extend* care*” or “long-term care” or “long term care” or “nursing home.” The literature searches included the criteria of being published in the English language and having a publication date of 2011 or later. The date of publication was selected in an effort to retrieve the most recent evidence related to management of HF. To be included, the study or guideline needed to be specific to LTC or skilled nursing services. Studies or guidelines specific to acute or home care were excluded from review. Additional criteria included the incorporation of disease management strategies into the intervention.

The initial search for literature within the CINAHL database resulted in 25 possible sources, of which five were selected. These sources were selected first by reviewing titles for applicability; next duplicate articles were removed; and finally those lacking inclusion criteria were removed. Abstracts and full articles were reviewed to determine if they met the inclusion criteria. A Medline database search resulted in 151 potential sources. One source was selected for review, using the same review techniques as the CINAHL search. A search within Health Source: Nursing/Academic Edition resulted in 33 potential sources. After removing duplicate articles, none were selected for review. The Proquest database search resulted in 47 potential sources; after removing for duplication and assessing applicability, no sources were selected. A hand search of the references from the selected sources of literature was completed with no additional sources. Finally, after reviewing titles, abstracts, and full articles, seven sources of evidence were determined appropriate.

The National Guidelines Clearing House was also searched for guidelines specific to HF in LTC or skilled nursing service settings. This search yielded three results, with two deemed appropriate for inclusion.

Evidence Evaluation

An evidence rating system developed by Melynyk and Fineout-Overholt¹¹ was used to determine the hierarchy of evidence. Systematic reviews or meta-analyses of randomized control trials (RCTs) and clinical practice guidelines based on systematic reviews or meta-analyses are given a rating of Level I evidence. Evidence from single RCTs are given a rating of Level II, and evidence from well-designed trials without randomization are given a rating of Level III. Level IV evidence is from well-designed case-control or cohort studies. Level V evidence includes evidence from systematic reviews of descriptive and qualitative studies. Level VI includes evidence from single descriptive or qualitative studies, and Level VII includes evidence from expert opinion, reports of expert committees, or the opinion of authorities. Table 1 provides a listing of the evidence chosen for review.

The Rapid Critical Appraisal Checklists was used to appraise the strength of the selected evidence for validity, reliability, and applicability.¹¹ Since the checklists do not include a numerical rating system to evaluate the quality of evidence, a system was created using a 3-point scale. For each hierarchy of evidence, three questions are raised: (1) Were the results valid? (2) Were the results reliable? (3) Will the results help in caring for my population? A source of evidence meeting the majority of criteria for all three questions was given a score of 3. A source not meeting the majority of criteria for one question was given a score of 2, and a source not meeting the majority of criteria for two questions was given a score of 1 (Table 1). All sources of evidence were included to provide a thorough review of the findings. Two sources of Level I evidence, two sources of Level III evidence, two sources of Level IV evidence, and one source of Level VII evidence were selected for review.

Following critical appraisal of the evidence, various barriers and challenges to managing HF within LTC were identified. However, we also identified several practices within the reviewed literature that were cited as contributing to the successful management of HF in this setting.

Transitions of Care

One key aspect of successful disease management is smooth transition from acute care. Evidence in the literature identified a lack of communication between acute and skilled nursing services as a barrier to smooth transitions in care.^3,7,9,12 One potential method to improve communication between facilities that was highlighted in the literature is for LTC facilities to implement HF care protocols.^3,7,13 Martinen and Freundl³ conducted a quasi-experimental study and reported that the initiation of HF protocols in LTC strengthens the continuum of care between settings. Nazir and colleagues¹² also recommended models of care for disease management. Jacobs⁷ reported a proactive approach in acute care by implementing a telephone follow-up between acute care staff and LTC staff to improve continuity of care and clarify discharge orders. Readmission rates were reduced from 30% to 11.32% as a result of this practice change.⁷

Team-Based Approach

Multiple types of professionals are employed by LTC facilities, ranging from licensed and certified staff to unlicensed support staff. A multidisciplinary team including nursing, dietary, and therapy services is recommended within LTC to improve outcomes.^9,12 When multidisciplinary team approaches were used in LTC, protocol implementation⁹ and HF management¹² were more successful. Nazir and colleagues¹² concluded that collaborative initiatives may result in enhanced team work, job satisfaction, and staff engagement. Multidisciplinary collaboration is essential to the management of HF when skilled nursing services are provided.⁹

Patient Education

Patient and caregiver education are important components to the management of HF.^3,10,12-14 Due to the chronic nature of HF, disease management education is essential, and an important component of this education is self-management strategies. Patient and caregiver education should be provided on topics related to HF¹⁰ and should include strategies for health maintenance and disease management.¹⁴ With increased knowledge, self-care activities can be improved, thus reducing exacerbations.³ Schipper and colleagues¹⁴ recommended referral to dieticians for diet-specific education. In one study, patients’ knowledge improved by 65% with the incorporation of patient education as part of the discharge process.³ Underperformance of HF management precipitated the design of a quantitative study when two educational sessions were provided.¹² Results did not show improvement in patient knowledge; however, a 75% improvement in staff knowledge was reported.¹² Improving staff knowledge strengthens the provision of care in HF management.

Staff Education

The incorporation of staff training and education is an essential component of HF management.^9,12,13 Education topics should include disease management and dietary restrictions. Regular staff education sessions tailored to all levels of providers is recommended to improve HF outcomes.¹² Additionally, Dolansky and colleagues⁹ found that staff education resulted in successful implementation of HF protocols. Staff training and education preceding the implementation of patient education programs is essential to success.¹²

Weight Monitoring

Fluid retention is a characteristic symptom of HF. Changes in weight when identified and treated early can reduce disease complications and potentially avoid hospitalizations. Monitoring body weight daily should be included as part of successful management.^3,7,10,12-14 Facilities should implement protocols for changes in weight. These protocols may include additional assessments and notifying the resident’s primary care physician.¹⁰ In one study, a weight monitoring regimen improved symptom management 100% from baseline.³ As part of the continuity of care program, acute care nurses verified that daily weight monitoring was ordered during a follow-up phone call to staff in LTC facilities.⁷

Sodium Restriction

Patients with HF need to follow certain dietary restrictions as instructed by their primary care provider. Increased dietary sodium intake can potentiate exacerbations. A restricted sodium diet is recommended^10,13,14 and must be implemented as part of a HF management program.

Due to the high numbers of patients with HF who transition to skilled nursing services after hospitalization, it is important for these facilities to provide care based on best practices. Incorporating EBP into the care of patients with HF receiving skilled nursing services has been shown to reduce readmission to the hospital.

The evidence reviewed here demonstrates multiple strategies to reduce readmission to the hospital. Incorporation of EBPs was shown to improve disease management. The evidence supports the necessity of the following components: smooth transitions of care, multidisciplinary team approach, patient and caregiver education, LTC staff education, weight monitoring protocols, and sodium restrictions for diets. Facilities offering skilled nursing services should examine their current practices for the management of HF and incorporate these best practices into standard care.

One limitation of this review is the limited information specific to LTC settings that was available. A multitude of evidence exists for the management of HF within acute, primary, and home care settings. Although many of the strategies for management are similar, LTC settings are faced with specific challenges related to the setting. The majority of patients admitted to LTC are elderly. Elderly patients pose additional difficulties in disease management due to multiple comorbidities, cognitive issues, and lack of social support.⁴ Another issue that can affect care within the LTC setting is related to staffing. Nursing care within the LTC setting may be provided by registered nurses, licensed practical nurses, and unlicensed certified nursing staff. Staffing ratios differ within facilities and nurses may provide care for as many as 20 patients. Many LTC facilities lack standardized education, assessment, and nursing interventions for patients with HF.¹²

In addition to limited evidence, two of the sources were of weak quality because they lacked a sufficient sample size and did not produce statistically significant results.^3,12 While these quality scores were lower, the findings mirrored the other sources of evidence and were included. The challenges identified during implementation in these studies may assist another facility implementing best practices for HF management because EBP was incorporated into the interventions of both studies.

Over the last decade, LTC facilities have evolved into post-acute care centers, providing transitional care for HF after hospitalizations. HF can be managed successfully in the LTC setting, despite the unique challenges of disease management. LTC should include: smooth transitions in care, team based approaches to care, patient and staff education, weight monitoring, and sodium restriction. The incorporation of these evidence- based management and monitoring strategies is an important component. The incorporation of evidence-based practice is shown to improve patient outcomes thus reducing the costs associated with disease management. 

Author:
Sara A Golden, DNP, RN, NP-C, FNP-BC

Affiliations:
Valparaiso University, Valparaiso, IN

Disclosures:
The author reports no relevant financial relationships.

Acknowledgements:
Theresa A Kessler, PhD, RN, ACNS-BC, CNE, for her guidance and support.

Address correspondence to:
Sara Golden
Valparaiso University
PO Box 1035 Goshen, IN 46527
Phone: (574) 294-7403
Fax: (574) 537-4067
Email: sara.golden@valpo.edu