JOURNAL OF COMMUNITY HEALTH NURSING, 2006, 23(3), 137146 Copyright 2006, Lawrence Erlbaum Associates, Inc.

Telephone Interventions by Nursing Students: Improving Outcomes for Heart Failure Patients in the Community
Erlinda C. Wheeler, DNS, RN, and Julie K. Waterhouse, PhD, RN
University of Delaware

Community care for heart failure patients is difficult due to multiple comorbidities, polypharmacy, and advanced age of patients. Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in home and community settings. The purpose of this study1 was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of heart failure patients in the home. Senior students were paired with community nursing staff and assigned 2 heart failure patients to follow up by telephone calls for 12 to 14 weeks. Patients who received telephone interventions had fewer hospital readmissions (13%) than the comparison group (35%). Patients in the telephone intervention group also had fewer overt heart failure symptoms as measured by the Minnesota Living With Heart Failure Questionnaire.

Mounting health care costs in the care of the elderly with chronic illness can lead to innovative and cost-efficient ways of caring for these patients. Worldwide, an estimated 23 million people have heart failure (HF), with 2 million new cases a year (Global Information, 2002). An estimated 5 million Americans have HF, with 550,000 new cases per year (American Heart Association, 2006). In the United States, HF is the leading cause of hospitalization in people over 65 years old, with an estimated direct and indirect cost of $29.6 billion for 2006. Due to their age, many of the HF patients have multiple comorbidities, polypharmacy, and difficulty in following complex therapeutic and dietary plans of care. Because of the complexity of the medical regimen and plans of care, there is potential for noncompliance. Nonadherence to the therapeutic regimen can lead to disease exacerbation and hospital readmission. In fact, one third of hospitalized patients with HF are readmitted within 90 days (Fonarow, 2002).

Correspondence should be addressed to Erlinda C. Wheeler, School of Nursing, McDowell Hall, Newark, DE 19716. E-mail: ewheeler@udel.edu 1Funded by General University Research Grant, University of Delaware and Center for Academic Practice, College of Health and Nursing Sciences, University of Delaware.

138

Wheeler and Waterhouse

Studies show that hospital admissions and emergency room visits decrease with increased nursing interventions in the home and community settings. Several programs have been implemented to decrease readmission rates of heart failure patients (Ahmed, 2002; Martinen & Freundl, 2004). Newly discharged HF patients need education, regular assessment of their condition, and close monitoring of their complex therapeutic regimens (Quaglietti, Lovett, Hawthorne, Byler, & Atwood, 2004). However, there are limited resources to provide for nursing interventions and care of HF patients in their homes. The purpose of this pilot study was to assess the effectiveness of regular telephone interventions by nursing students on outcomes of HF patients in the home.

REVIEW OF LITERATURE Relationship Between Interventions and Outcomes HF patients are currently hospitalized only when severely ill and are often discharged early in the recovery period. These short, acute hospital stays often result in patients being discharged with inadequate self-care instructions (Knox & Mischke, 1999; Wehby & Brenner, 1999). Patients with severe HF may have difficulty concentrating enough to learn new information, and lack of understanding may then result in increased readmission rates. Stewart, Vandenbroek, Pearson, and Horowitz (1999) concluded that most HF patients had insufficient understanding of their treatment regimen and that half were not compliant with their medications. According to Knox and Mischke (1999), 50% of hospitalizations for HF could have been avoided with a well-designed management program involving a multidisciplinary team. Research shows that the high readmission rates for HF patients can be decreased by various inpatient and outpatient health care interventions. Results of a 1999 study by Knox and Mischke showed that a multidisciplinary inpatient disease management program led to shorter hospitalizations, lower readmission rates, and improved compliance with treatment regimens. Dahl and Penque (2000) reported on the effects of an inpatient HF program based on the Agency for Healthcare Research and Quality guidelines. This program, directed by an advanced practice nurse, was found to significantly decrease mortality, length of stay, and 90-day readmission rates. Several studies suggest positive HF patient outcomes from well-planned community interventions (Dunagan et al., 2005; Martens, 2000; Martens & Mellor, 1997; Proctor, Morrow-Howell, Li, & Dore, 2000; Stewart et al., 1999). Stewart et al. used outpatient home visits with counseling to improve compliance and allow earlier recognition of signs and symptoms of HF. Paul (2000) found that outpatient follow-up provided by a team consisting of a nurse practitioner, a pharmacist, a physician, a dietician, and a social worker improved patient outcomes.

Telephone Interventions

139

Ahmed (2002) conducted a meta-analysis of randomized trials of multidisciplinary disease management programs in HF. The studies analyzed had a combined total of 1,937 HF patients. Results showed that there was a 13% lower risk of hospitalization for patients receiving care from HF disease management programs compared to those receiving usual care. Although special clinic and home care interventions have been shown to decrease rehospitalizations for HF, these interventions are not widely available, for two major reasons. The additional interventions can add substantially to health care costs (Rich et al., 1995; Rich et al., 1993), and managed care plans and other insurance may not reimburse for this care. Compounding this problem, the current shortage of nurses and other health care personnel means that staff resources are often insufficient to provide the extra interventions to HF patients in the home.

The Value of Telephone Interventions Research suggests that telephone interventions can improve outcomes for patients with diverse medical diagnoses. A review of 80 clinical trials of provider-initiated electronic communication with patients at home showed significantly positive outcomes in the areas of cardiac rehabilitation, diabetes care, and preventive care (Balas et al., 1997). Hunkeler and Meresman (2000) reported that regular telephone calls by nurses over a 6-month period reduced symptoms in 58% of patients with depression. Savage and Grap (1999) reported on a study involving telephone interventions (providing reassurance; emotional support; and information on medications, diet, and activity) with cardiac surgery patients. This telephone monitoring was found to alleviate the stress of transition between postoperative hospital care and recovery at home. Three studies examined telephone interventions with HF patients at home. Dahl and Penque (2000) studied a nurse-directed HF program that included follow-up telephone calls to high-risk HF patients after discharge. Regular calls from nurses to reinforce teaching and provide emotional support resulted in reduced mortality rates and lower hospital readmission rates for the HF patients in this program. A study done by Draus, Walblay, and Barraco (2002) used telemanagement by an advanced practice nurse to follow-up newly discharged HF patients. Although the results showed no significant differences in readmission rates of patients before and after enrollment, total health care charges decreased significantly. Additionally, a downward trend in lengths of stay, inpatient charges, and outpatient visits was noted after program enrollment. A recent randomized study by Dunagan et al. (2005) showed that a nurse-administered telephone-based management program resulted in a longer interval between health care visits and a lower readmission rate for HF diagnosis. Published research provides sufficient evidence that many patients with HF benefit from interventions that include patient education, careful assessment, and regular moni-

140

Wheeler and Waterhouse

toring. Furthermore, research findings on telephone interventions suggest that HF patients may benefit from this lower cost approach. This study was designed to determine whether HF patients and student nurses could benefit from telephone interventions by the students. Our expectation was that the patients would benefit from the additional 10 to 12 weeks of follow-up after home care and that the students would benefit from the community experience of extended intervention with the same patient.

METHODOLOGY Setting This pilot study was conducted in a community setting, with a home health care agency (HHA) and a 4-year baccalaureate nursing program in a midsize university in the mid-Atlantic region of the United States. A telephone intervention program for patients with HF was initiated in the last clinical course of the senior year. This is a six-credit medicalsurgical clinical course with acute care and community components. The human subjects review boards of the university and the HHA granted approval for this study.

Sample A convenience sample of patients from the HHA with a primary diagnosis of HF was solicited to participate in the study, and each was asked to sign an Institutional Review Board approved consent form. Students also signed informed consents before the beginning of the study. Two patients were assigned to each of the students for a total of 20 patients in the telephone intervention group. A convenience comparison group of 20 patients with HF were identified from the cases of the home care agency, and chart review was done to obtain pertinent data. Demographic data and outcome measures (readmission rate and emergency clinic visits) were extracted from the charts of the participants in the comparison group.

Instruments Demographic data including age, gender, caregiver, number of medications, New York Heart Association classification, and number of comorbidities were gathered during the initial patient visit and from the charts of the control group. The Minnesota Living With Heart Failure (MLHFQ) questionnaire, the Problem Rating Scale of Outcomes, the Perception of Health Status, and the Quality of Life Scale were administered during the ini-

Telephone Interventions

141

tial home visit and at the end of the semester. In addition, students wrote weekly journals and documented emergency clinic visits and hospital readmissions. The MLHFQ is composed of 21 questions asking if the limitations commonly found in HF patients prevented them from living as they wished during the previous week. The patients were asked to rate each question on a scale of 0 (no) to 5 (very much). Patients without overt HF symptoms have significantly lower scores. Reliability and validity of the instrument have been well documented in the literature (Gorkin et al., 1993; Rector, Kubo, & Cohn, 1993). The Problem Rating Scale of Outcomes was based on the Omaha System, a systematic clinical-and research-based tool for assessment and documentation of patient outcomes (Martin & Scheet, 1992). The scale is based on the assumption that the interventions by the nurse are affected by the clients knowledge, behavior, and status. A Likert-type ordinal scale ranging from 1 (most negative) to 5 (most positive) was used to depict the client states in relation to specific problems. The problems that were rated by the students were diet and nutrition, physical activity, and prescribed medication regimen. In addition to the instruments described here, the patients in the intervention group were asked to rate their perception of health status, How would you rate your overall health status at the present time? on a scale of 1 (excellent) to 4 (poor) or 5 (no response), and their quality of life, How would you rate your quality of life in the last week? on a scale of 0 (worst) to 10 (best).

Procedure The students selected to participate in this study were second-semester seniors in their final clinical rotation before graduation. Students were oriented to the study and to what their role would be at the beginning of the clinical course. As the semester progressed, questions and issues were discussed during a weekly clinical postconference. Ten nursing students were each assigned to care for two patients with HF in the community. They were paired with a registered nurse in the HHA at the beginning of the semester. The student and the registered nurse visited the two HF patients to assess and document the patients conditions, home environments, and social support. Teaching about medical and therapeutic regimen was done or reinforced during the home visit. Under the direction of the nurse, the student familiarized herself or himself with the patient, family, and the environment. The home care nurses followed the HF patients for 1 to 4 weeks, depending on their health status and insurance coverage. After the patient was discharged from home care, he or she was followed for an additional 8 to 12 weeks by the student nurse. Afterward, students called the patients once or twice a week using a detailed protocol developed by the faculty (see Table 1). During the calls, students reinforced patients prior learning about their disease and treatment, encouraged compliance with medications and diet, and identified signs and symptoms of worsening HF. When appropriate,

142

Wheeler and Waterhouse

TABLE 1 Telephone Call Protocol

Goals: 1. Reinforce patients education. 2. Identify signs and symptoms of worsening heart failure. 3. Ensure compliance with medications and diet. Areas to assess: 1. Weightreinforce patients performance of monitoring daily weights. 2. Exacerbations of signs and symptoms (call your doctor): (a) Weight gain of 2 to 3 lbs in 24 hr or 5 lbs in 1 week (b) Increased lower extremity edema (c) Increased fatigue (d) Increased shortness of breath (e) Paroxysmal nocturnal dyspnea (f) Decreased urine output (g) Upper respiratory tract infection (h) New onset of nausea, vomiting, diarrhea (i) New onset of dizziness (j) Blood pressure greater than 180, systolic (k) Palpitations that may signify atrial dysrhythmia 3. Dietary restrictionswhat diet consisted of the previous day. Reinforce teaching regarding sodium and alcohol restriction. If taking diuretics encourage potassium-rich foods, and limit potassium if there is kidney damage. 4. Medicationsavailability of medications, compliance in taking medications. Ask about any side effects. If taking Digoxin, record pulse rate. 5. Activity and exerciseable to do activities of daily living. Shortness of breath with what activity. 6. Discuss importance of compliance with treatment/care plan. Identify and modify barriers to their compliance.

the student instructed the patient to call his or her primary caregiver, using the guidelines provided. Faculty was available by phone or pager 24 hr a day, if students had questions or needed assistance. Students provided telephone guidance for the patients until the end of the semester. The length of follow-up ranged from 12 to 14 weeks, depending on when HF patients became available for the study. The comparison group consisted of a convenience sample of 20 patients with a primary diagnosis of HF, selected from the same community agency. These patients received the usual follow-up from home care nurses but did not receive long-term follow-up from students. Data were analyzed using the SAS8.2 (2001) means, frequency, and t-test procedures and the chi-square option.

RESULTS The variable means, standard deviations, and frequency distributions for each group are presented in Table 2. Study participants averaged 72 years of age, were predominantly women, and had had HF for an average of 5 years. They took an average of 7.8 prescription medications apiece and typically had three or more comorbidities. Most were classified 2 or 3 on the New York Heart Association scale.

Telephone Interventions
TABLE 2 Demographic Characteristics of Patient Sample Intervention Group M Age (in years) Length of illness (in years) Number of medications Number of comorbidities Gender Male Female NYHA class I II III IV Note. 70.6 5.5 9.0 3.7 SD 15.1 6.2 3.0 1.9 6 14 2 13 4 1 30 70 10 65 20 5 n % M 73.4 10.3 6.9 3.0 Comparison Group SD 10.30 1.10 1.20 0.95 8 13 3 10 8 0 38.1 61.9 2.90 14.3 47.6 38.1 0.0 n % t 0.71 0.94 2.56 1.48 0.29 2

143

p .482 .364 .019 .150 .584

.407

NYHA = New York Heart Association.

The t tests and chi-square values associated with the intervention and comparison groups suggest that participants in the two groups were similar and had few significant differences. No significant differences were identified on age, gender, comorbidities, or length of illness. The individuals in the intervention group were found to take a significantly higher number of medications, t(18.9) = 2.56, n = 20, p = .019. In addition, individuals in the comparison group were found to have significantly more hypertension than those in the intervention group, 2(1, N = 20) = 4.36, p = .037. As illustrated in Table 3, more participants in the comparison group were readmitted during the 14-week study period (7 of 20, compared to 3 of 20 in the intervention group), but the difference was not significant, 2(1, N = 20) = 2.78, p = .095. Mean scores on the MLHFQ scales for those in the intervention group were lower at the end of the study period than at the beginning (33.53 at Week 14, compared to 38.45 at Week 1), but, again, the differences were not significant. Similarly, no significant differences were found on the Perceptions of Health Status or Quality of Life scales from the beginning to the end of the study. (The MLHFQ, Perception of Health Status, and Quality of Life scores were not available for the comparison group patients.)

TABLE 3 Frequency of Readmission Intervention Group Readmitted Within 12 Weeks Yes No n 3 17 % 15 85 Comparison Group n 7 13 % 35 65 2 2.78 p .095

144

Wheeler and Waterhouse DISCUSSION

As compared to patients who did not receive calls, fewer HF patients who received the long-term follow-up from nursing students were readmitted during the study period. Although the difference was not significant, the trend suggests that the telephone interventions may have decreased the readmission rate. This finding is supported by the literature that shows an increase in interventions for HF patients in the home decreases readmission rates (Knox & Mischke, 1999; Martens, 2000; Rich et al., 1995) A post hoc power analysis showed that the power to detect a difference in readmission rates with this sample size was only .38, so there was a 62% chance that a real difference would not be detected. The fact that the mean MLHFQ scores were lower at the end of the study is noteworthy. Persons with HF are expected to show a decline in function with time. The participants in this study who received the telephone interventions from nursing students improved slightly over the 3-month period. Although this improvement cannot be positively attributed to the telephone interventions, regular interactions with a knowledgeable health care provider may have had some influence. Similarly, Ohldin (2001) found that HF patients who were followed by telephone or home care visits showed significantly increased satisfaction with the level of care. An additional benefit of the telephone interventions by nursing students was the positive community learning experience that the activity provided for the students (see Wheeler & Plowfield, 2004).

Limitations Several limitations must be considered when interpreting the results of this research. The small sample size is an unquestionable limitation, as shown by the low power of the study. The relatively short period of study (one semester) is also a limitation. If the telephone interventions could have continued for a period of 6 to 12 months, significant changes in quality of living and readmission rates would have been easier to detect. Another limitation is the fact that no evaluation of the telephone intervention was obtained directly from the patients. Finally, this study included nursing students from only one university, and the students were all at the senior level.

Plan for Further Study To address the limitations of this pilot study, future research is planned to include other groups of senior nursing students and patients with other kinds of chronic illnesses, such as cancer and chronic lung disease. This should result in a considerably larger sample size and improve the power for the data analysis. The future study will be designed to in-

Telephone Interventions

145

clude a structured evaluation by patients at the end of the intervention. We also plan to increase the length of the telephone intervention period by obtaining funding to continue the calls between semesters. Finally, repetition of this research at different universities and with nursing students at different levels will improve the external validity of the study.

CONCLUSIONS Telephone interventions by students appear to be effective in achieving positive outcomes in HF patients in the community, particularly in light of the increased cost of such interventions by staff and the scarcity of nursing resources. The approach provides good learning experiences for students and seems to improve quality of life and reduce readmission rates for patients. The literature review suggests that many types of patients can benefit from telephone interventions by nurses, so outcomes for patients with other kinds of chronic illnesses may also be improved using telephone interventions by nursing students.

REFERENCES
Ahmed, A. (2002). Quality and outcomes of heart failure care in older adults: Role of multidisciplinary disease-management program. Journal of American Geriatric Society, 50, 15901593. American Heart Association. (2006). Heart and stroke statistics2006 update. Dallas, TX: Author. Balas, E., Jaffrery, F., Kuperman, G., Boren, S., Brown, G., & Pinciroli, F. (1997). Electronic communications with patients. Journal of the American Medical Association, 278(2), 152158. Dahl, J., & Penque, S. (2000). The effects of an advanced practice nurse-directed heart failure program. Nurse Practitioner, 25(3), 6177. Draus, C., Walblay, A., & Barraco, D. (2002). Partnering for congestive heart failure: A clinic without walls. Outcomes Management, 6(1), 4043. Dunagan, W. C., Littenberg, B., Ewald, G. A., Jones, C. A., Emery, V. B., Waterman, B. M., et al. (2005). Randomized trial of a nurse-administered, telephone-based disease management program for patients with heart failure. Journal of Cardiac Failure, 11(5), 358365. Fonarow, G. (2002). Medical management of heart failure in the elderly: Clinical evidence and practical concerns. Annals of Long Term Care, 10(6), 115. Global Information. (2002). Congestive heart failure: Worldwide drug and medical device markets. Retrieved August 8, 2003, from http://www.the-infoshop.com/study/k110410_congestive_heart_failure Gorkin, L., Norvell, N., Rosen, R., Charles, E., Shumaker, S., McIntyre, K., et al. (1993). Assessment of quality of life as observed from the baseline data of the studies of left ventricular dysfunction (SOLVD) trial quality of life substudy. American Journal of Cardiology, 71, 10691073. Hunkeler, E., & Meresman, J. (2000). Nurse care by phone improves outcomes for depressed patients. Archives of Family Medicine, 9, 700708. Knox, D., & Mischke, L. (1999). Implementing a congestive heart failure disease management program to decrease length of stay and cost. Journal of Cardiovascular Nursing, 14(1), 5574. Martens, K. (2000). Home care nursing for persons with congestive heart failure: Description and relationship to hospital readmission. Home Healthcare Nurse, 18(6), 404409.

146

Wheeler and Waterhouse

Martens, K., & Mellor, S. (1997). A study of the relationship between home care services and hospital readmission of patients with congestive heart failure. Home Healthcare Nurse, 15(2), 123129. Martin, K., & Scheet, N. (1992). The Omaha System: Applications for community health nursing. Philadelphia: Saunders. Martinen, M., & Freundl, M. (2004). Managing congestive heart failure in long-term care: Development of an interdisciplinary protocol. Journal of Gerontological Nursing, 30(12), 512. Ohldin, A. (2001). Observations from a home-based congestive heart failure intervention. Home Care Provider, 6(6), 212217. Paul, S. (2000). Impact of a nurse-managed heart failure clinic: A pilot study. American Journal of Critical Care, 9(2), 140146. Proctor, E., Morrow-Howell, N., Li, H., & Dore, P. (2000). Adequacy of home care and hospital readmission for elderly congestive heart failure patients. Health and Social Work, 25(2), 8796. Quaglietti, S., Lovett, S., Hawthorne, C., Byler, A., & Atwood, J. (2004). Management of the patient with congestive heart failure in the home care and palliative care setting. Home Health Care Consultant, 12(1), 1421. Rector, T., Kubo, S., & Cohn, J. (1993). Validity of the Minnesota Living with Heart Failure Questionnaire as a measure of therapeutic response to Enalapril or placebo. American Journal of Cardiology, 71, 11061107. Rich, M., Beckham, V., Wittenberg, C., Leven, C., Freedland, K., & Carney, R. (1995). A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. New England Journal of Medicine, 333, 11901195. Rich, M., Vinson, J., Sperry, J., Shah, A., Spinner, L., & Chung, L. (1993). Prevention of readmission in elderly patients with congestive heart failure. Journal of General Internal Medicine, 8, 585590. Savage, L., & Grap, M. J. (1999). Telephone monitoring after early discharge for cardiac surgery patients. American Journal of Critical Care, 8(3), 154159. Stewart, S., Vandenbroek, A., Pearson, S., & Horowitz, J. (1999). Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Archives of Internal Medicine, 159, 257261. Wehby, D., & Brenner, P. (1999). Perceived learning needs of patients with heart failure. Heart and Lung, 28(1), 3140. Wheeler, E., & Plowfield, L. (2004). Clinical education initiative: Caring for CHF clients in the community. Nursing Education Perspectives, 25(1), 1621.