Transitional Care Management and the Homebound Older Adult with CHF
By Anquinette Cray and Ron Billano Ordona
The at-risk population is the older adult 65 years and older, homebound, with congestive heart failure (CHF).
They are at greater risk for emergency department (ED) visits or hospital admissions and readmissions. According to our quality improvement project results (Ordona, 2018), homebound seniors with CHF are five times more likely to be readmitted to the ED/hospital.
This is associated with greater use of health resources, morbidity, and mortality (Yang, Ornstein, & Reckrey, 2016). The Centers for Disease Control and Prevention (2016) estimated there are six million adults in the United States with heart failure. The national healthcare cost is approximately over $3 billion. CHF also diminishes the quality of life by 80% for individuals over the age of 65 (Punchik et al., 2017).
The aggregated statistical data of the risk factors, according to the American Heart Association (AHA, 2017), states that in 2010 the estimated cost of heart disease was $863 billion globally and is expected to rise to $1 trillion.
According to the AHA, coronary heart disease results in 45.1% of deaths in the United States, followed by stroke 16%, heart failure 8%, and hypertension 9%.
The vulnerable population may have a lack of instrumental support, neighborhood, and community resources. Multiple chronic conditions associated with coping, diminished social support, and a sense of loss of control increase the stress of life.
Linking these individuals to needed resources such as education, planning, social support, and community resources can improve this population group’s quality of life. Cardiovascular disease and its risk factors affect patient independence.
Resources for Health Promotion for CHF
Transitional care management is a resource for those transitioning from higher level of care (hospital or skilled nursing facility) to home.
Transitional care management should be facilitated safely and timely across care settings (Allen, Hutchinson, Brown, & Livingston, 2017). Meleis’s (2010) transitional theory notes vulnerability as change in the healthcare continuum occurs. Health management during this time is important to avoid fragmented care.
External factors need to be addressed outside of the hospital or skilled nursing facility to assist with the transition to home. Internal factors involve care coordination with formal caregivers (home health nurses) or informal caregivers (families, friends or in-home caregivers).
Anquinette Cray, MSN, FNP-C
Ron Billano Ordona, DNP, FNP-BC
Note: Ms. Cray is working on her Doctor of Nursing Practice (DNP) project with Grand Canyon University, an offshoot from Dr. Ordona’s previous work on transitional care medical house calls for homebound seniors. Ms. Cray aims to measure perception of home health nurses in caring for homebound seniors during transitions of care in collaboration with the nurse practitioner implementing transitional care medical house call visits.
Dr. Ordona is the GAPNA Housecalls SIG chair. The SIG meets remotely via tele/videoconference every first Thursday of the month at 5:30 p.m. (pacific).
- Allen, J., Hutchinson, A.M., Brown, R., & Livingston, P.M. (2018). User experience and care for people transitioning from hospital to home: patients’ and carers’ perspectives. Health Expectation, 21(2), 518-527. doi:10.1111%2Fhex.12646.
- American Heart Association (AHA). (2017). Heart disease and stroke statistics 2017 at-a-glance. Retrieved from https://healthmetrics.heart.org/wp-content/uploads/2017/06/Heart-Disease...
- Centers for Disease Control and Prevention. (2016). Interactive atlas of heart disease and stroke. Retrieved from https://nccd.cdc.gov/DHDSPAtlas/Reports.aspx
- Meleis, A.I. (2010). Transitions theory: Middle range and situation specific theories in research and practice. New York, NY: Springer Publishing Company.
- Ordona, R. B. (2018). Transitional care medical house call: A pilot project. Boise State University Repository. Retrieved from https://scholarworks.boisestate.edu/dnp/14
- Punchik, B., Komarov, R., Gavrikov, D., Semenov, A., Freud, T., Kagan, E, Goldberg, Y., & Press, Y. (2017). Can home care for homebound patients with chronic heart failure reduce hospitalizations and cost? PLoS ONE, 12(7). doi:10.1371/journal.pone.0182148
- Yang, N., Ornstein, K., & Reckrey, J.M. (2016). Association between symptom burden and time to hospitalization, nursing home placement, and death among the chronically ill urban homebound. Journal of Pain Symptom Management, 52(1), 73-80. doi: 10.1016/j.jpainsymman.2016.01.006
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