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Home visits by a cardiac nurse clinician and patients diagnosed with heart failure Krzyczkowski, Jennifer Jane


Heart failure (HF) is a debilitating syndrome affecting thousands of Canadians every year. It is one of the leading causes of death in Canada and has been found to be the leading cause of readmission to hospital in North America. We sought to determine if home visits by a cardiac nurse clinician reduced heart failure readmissions to hospital in Canada. A retrospective cohort study design examined the effect of an existing post-discharge home visit intervention program for patients with heart failure. The study sample consisted of 215 patients, each hospitalized with a “most responsible inpatient diagnosis of heart failure.” Between 2011 and 2013, 103 patients were referred to the home visit intervention program and seen by the cardiac nurse clinician at home. The usual care group 112 patients was randomly extracted from Discharge Abstract Database between 2009 and 2011. Meleis’ Transitions Theory informed and guided the study, and Wagner’s Chronic Care Model guided the intervention. The main outcome measure was 30-day hospital readmissions for heart failure. The intervention group had fewer readmissions to hospital for heart failure and a higher number of referrals to cardiac rehabilitation than usual care group (p ≤ 0.001). No significant differences were found between all-cause readmissions, length of stay of readmissions, or all-cause emergency visits between the two groups. Our results suggest that there may be a relationship between home visits by a cardiac nurse clinician and heart failure readmissions with patients who are diagnosed with heart failure. Furthermore, we believe the model may be beneficial for treatment of other cardiac patients. There may be a cost saving for the healthcare system in reducing heart failure readmissions to hospital; however, we recognize that a proper cost analysis is needed to confirm the economic benefits of the model. More work is needed in testing this intervention in other geographic areas (e.g., rural), as well as with patients who have different socioeconomic characteristics. A more rigorous study design, such as a randomized controlled trial or interrupted time series, is needed to further test the model of home visits with those patients who suffer from heart failure.

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