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Improving Patient and Caregiver Engagement During the Transition of Care to Improve Health Outcomes in Patients 65 Years and Older with Heart Failure.

Oriowo, Oluremi Omolara
http://rave.ohiolink.edu/etdc/view?acc_num=xavier1512646682649032

Abstract Details

2017, Doctor of Nursing Practice Degree Program in Population Health Leadership DNP, Xavier University, Nursing.
Abstract Introduction: Heart Failure (HF) is challenging to patients, families, and healthcare providers because of the heavy symptom burden and frequent hospitalizations. About one million adults over 65 years of age are hospitalized for HF per year in the United States of America alone.1 Though post-discharge services to prevent readmission are increasing; the readmission rate is, however, not declining.2 Healthcare providers could empower patients to engage in self-management by leveraging individualized health determinants to achieve the desired outcome. The aims of the project were to improve self-management ability through patient engagement during admission and transitional period and to prevent unnecessary readmission and emergency department utilization post hospitalization. Literature Review: Meaningful partnerships with patients and families are essential for achieving the federal government’s healthcare triple aims to improve quality of care, improve patient experience and reduce healthcare cost.3 Heart failure transition of care programs to improve health outcomes post hospitalization include common themes such as telephone follow up, education, self-management, weight monitoring, dietary advice, exercise, social and psychological support. 2 In studies of patient activation for self-management, positive relationships were suggested between the amount of knowledge, skill and confidence about handling chronic conditions, referred to as “engaged,” and the ability to manage care, promote health, and make better decisions affecting one’s condition.4 Significance: Healthcare providers and organizations who provide care and receive payment for services to beneficiaries of CMS are motivated to reduce readmission of HF patients because of the financial implications. Reduction in the readmission rate of HF patients, 65 years and older, is therefore significant to the healthcare organization, stakeholders, nursing and for improving the population health outcomes. Patient focused outcomes such as patient satisfaction, quality of life, functional status, knowledge of discharge diagnosis, preparedness for discharge, and self-management skills and ability are essential, and could positively impact the rate of readmission for this patient population. Theoretical Framework: In order to achieve the Institute of Healthcare Improvement’s Triple Aim, patients must be empowered to become adequately informed, make healthcare choices, and adopt healthier lifestyles that will impact the quality of their health, experience of care, and reduce the cost of care. Patient empowerment is achieved through collaboration among healthcare team, and in partnership with patients and family. Methodology: The design for the project was descriptive pre-and post-intervention. Informed consent was obtained from eligible participants and caregiver with patient’s permission. The Patient Activation Measures (PAM) score level was used to categorize participants. A targeted improvement intervention based on the activation level was implemented. Data were analyzed quantitatively. Results: Sixty-two and a half percent of patients who completed the three PAM surveys and had education interventions, and had at least one level of increase in activation level. Eighty-seven percent of patients who completed the project did not get readmitted within 30 days of index admission. All three patients with caregiver involvement remained out of the hospital for at least 30 days after discharge. Findings were shared with the organization for the DNP student project to inform transitional care planning for elderly HF patients. Discussion: The findings from this project support the ability of the PAM to identify a patient’s activation level, and to measure improvement following the project intervention. The 30-days HF readmission rate for the participants was also lower than the overall baseline rate for the hospital. The short duration of the project affected the number of patients enrolled to participate in the project. Conclusion: Improvement in self-management ability of HF patients 65 years and older, through patient engagement during the admission and transitional period could prevent unnecessary readmissions and emergency department utilization post hospitalization. Extending the project duration six to nine additional months, may allow for obtaining additional information about the long term impact of the educational intervention on the HF population.
Susan Allen, Ph.D. (Committee Chair)
Susan Schmidt, Ph.D. (Committee Member)
73 p.
Nursing
Transition of Care; Readmission; Patient engagement; Self-management

Recommended Citations

Citations

  • Oriowo, O. O. (2017). Improving Patient and Caregiver Engagement During the Transition of Care to Improve Health Outcomes in Patients 65 Years and Older with Heart Failure. [Doctoral dissertation, Xavier University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=xavier1512646682649032

    APA Style (7th edition)

  • Oriowo, Oluremi. Improving Patient and Caregiver Engagement During the Transition of Care to Improve Health Outcomes in Patients 65 Years and Older with Heart Failure. 2017. Xavier University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=xavier1512646682649032.

    MLA Style (8th edition)

  • Oriowo, Oluremi. "Improving Patient and Caregiver Engagement During the Transition of Care to Improve Health Outcomes in Patients 65 Years and Older with Heart Failure." Doctoral dissertation, Xavier University, 2017. http://rave.ohiolink.edu/etdc/view?acc_num=xavier1512646682649032

    Chicago Manual of Style (17th edition)

xavier1512646682649032
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© 2017, all rights reserved.
This open access ETD is published by Xavier University and OhioLINK.