Role of patient education in reducing readmission for heart failure



Heart failure isamong the diseases that have been affecting human beings overcenturies. According to CDC, there are over 5.7 million heart failurepatients in the USA. It is one of the major causes of death since oneout of nine deaths was caused by the disease in 2009. Onceindividuals develop the disease, they lose hope of recovery. Thedisease is life-threatening because CDC reports that approximately50% of the patients suffering from it die within five years ofdiagnosis. Despite the disease being considered to affect theelderly, over 1.5 million of the heart failure patients in the UnitedStates are below the age of 60 years.

Mann, D. L., &ampFelker, G. M. (2016) describe heart failure as a multisystem disorderthat is characterized by major disturbances in the circulatoryphysiology and several myocardial structural and functional changes.The changes adversely affect the normal systolic pumping capacity anddiastolic filling of the heart. The changes do not necessarily meanthat the heart has stopped beating. However, it is not functioningnormally. The changes in the cardiovascular system are associatedwith inadequate pumping of blood, backing up of blood in the veins,edema in the feet, ankles and legs, pulmonary edema, and insufficientsupply of oxygen and food to respiring cells. Coronary arterydisease, heart defects, hypertension, myocardial infarction,diabetes, obesity alcohol, certain types of chemotherapy, anddisorders of the cardiac muscles are some of the causes of heartfailure.

The disease ismanageable. Heart failure patients can prolong the life when theymanage it effectively. After diagnosis, patients are hospitalized andsubjected to management therapies. They are discharged once theircondition improves. In some cases, patient’s health status getsworse after being discharged, and they may be required to bereadmitted. Readmission may be a result of inadequacy in treatmentand follow-up. There are various strategies that are used in reducingpatient readmission. Educating individuals with heart failure canhelp in the effective implementation of the strategies. It involveshealth professionals imparting patients with information that willhelp alter their behaviors in order to improve their health status.This paper evaluates patient education and strategies of reducingpatient readmission for heart failure.


Heart failure isamong the major causes of admission of adults above the age of 65years. Since there is increasing cases of readmission, there is thelikelihood of increment in the annual expenditure. Readmission isassociated with worsening of the heart failure disease and inadequatepatient education. Programs for reducing patient readmission havebeen aiming at reducing the cost of management of the disease andimproving the health status of the patients. The best individuals toimplement readmission reduction plans are the patients because theyare the ones in need. However, they need information to execute theirresponsibilities. Since education provides patients with relevantinformation about the disease, they can utilize it to benefitthemselves, prevent readmission and worsening of their health status.


Patient educationis not effective in reducing heart failure patient readmission

Literature review

In order tounderstand the methods employed in reducing readmission in heartfailure, it is important to understand the causes of readmission. Theeffectiveness of various strategies can be determined by finding outwhether their components address the causes of rehospitalization.This literature review discusses the causes of readmission in heartfailure. The strategies available for reducing readmission aredescribed. It then describes the functions of patient education inheart failure management.

Causes ofreadmission

Theidentification and analysis of the factors that cause readmission forheart failure is important since they help healthcare professional toformulate strategies for educating patients and reducing it.Aggarwal, S., &amp Gupta, V. (2014) realized the lack of detaileddescription of the causes and preventability of readmission. Suchcondition hampers development and effective implementation of thestrategies. Therefore, Aggarwal, S. &amp Gupta, V. (2014) conducteda study to determine the causes of readmission thirty days afterdischarge. They collected data for 2,536,439 admissions nationwidefrom Agency for Healthcare Research and Quality, and NationwideInpatient Sample. The sources of data used in the study provided theinformation caregivers recorded during patient visits. The causes ofreadmission can be identified from the secondary sources. From thestudy, the rehospitalization rate for heart failure was 24.88%. Thestudy identified renal failure, arrhythmia, septicemia, and pneumoniaas the primary diagnoses for heart failure readmission. Therefore, aneffective strategy is that which is focused on the reduction of therisk factors of the health conditions.

The causes ofreadmission can be categorized. Categorization enables formulation ofspecific interventions that results in improvement in the search forways of reducing it. Edward K. (2012) carried out a study todetermine the causes of patient readmission for heart failure. Thecategories include patient, physician, system and disease-specificfactors, and those beyond one’s control. The disease-specificfactors which risk a heart failure patient of being readmittedinclude the occurrence of azotemia, arrhythmia, anemia, bloodpressure extremes, diabetes, electrolyte balance disturbance,ischemia, pulmonary infections, and optimal medical therapy. EdwardK. (2012) reports that patient factors contribute to over 66% of thecauses of readmission. Lack of adherence to medication and diet,behaviors and lifestyle, social isolation, inadequate funds, culturalfactors, and lack of understanding of the instructions are examplesof patient factors. Lack of understanding can be caused by absence ofpatient education, language barrier, denial, and psychiatric issues.

Physicians arealso responsible for the increasing rate of readmission for patientswith heart failure. They may cause readmission by providinginadequate instructions, prescribing inadequate diuretic dischargedose, discharging patients too early, and duplicate medications. Thetreatment of heart failure should incorporate consultation. When itis included, physicians are likely to provide appropriateinstructions to patients. In the system category, more than half ofthe readmissions are based on the issues of the previous admissions.From this study, it is evident that follow-up program plays animportant role in identifying and managing situations that may resultin rehospitalization. Lack of home-based care for the patientsincreases their chances of readmission. Edward K. (2012) reports that61% of the readmitted patients had no home health referral andeducation program.

In their study,Annema C., Luttik M. &amp Jaarsma T. (2011) stressed the importanceof exploring the different perspectives of the causes of subsequentadmission for heart failure in optimizing the management of thedisease. The aim of the study was to provide insights into the causesof readmission from the perspectives of patients and varioushealthcare specialists. The study based on 173 cases ofrehospitalization. Data collection methods such as interviews andquestionnaire were used in studying the various perspectives. Theworsening of the patient’s condition was the major cause ofsubsequent admission. Patient’s awareness on the conditions thatworsen their health was lacking. The study found out thatcomorbidity, non-adherence, and non-optimal medication are importantcontributing factors to readmission cases. Lateness and lack ofmultidisciplinary approach to the disease management are also causesof the readmission. The study recommended patients to have adequateinformation on the risks of readmission using the differentperspectives.

Gheorghiade etal. (2013) narrow down to the main pathophysiological cause ofreadmission for heart failure. Congestion associated with high leftventricle filling pressure may be caused by the various cardiacabnormalities such as heart attack and arrhythmia. Congestion is acondition that gradually develops before admission. However, patientsmay have high left ventricular filling (LV) pressures withoutcongestion. The high LV pressure is responsible for the progressionof heart failure through subendocardial ischemia, altered LVgeometry, stimulation of the renin-angiotensin-aldosterone system,triggering of inflammation modulators, and deterioration of renalfunction. The study recommended the inclusion of the risk reductionof the factors that increases LV filling pressure into the strategiesfor decreasing the rate of readmission.

Role ofpatient education

White M et al.(2013) found out that lack of understanding of instruction bypatients at the time of discharge was responsible for thereadmission. When patients fail to understand instructions on themanagement of their health condition, effective implementation of thestrategies is almost impossible. They become likely to attach reducedvalue to the strategies used in both inpatient and outpatientsettings. The instructions at the time of discharge are essentialsince they provide patients with guidelines on the steps and how bestto implement the home-based care. Education also enables the patientsto understand their role in the management of heart failure.Furthermore, they become aware of the various stakeholders and therole they play to improve their health. Understanding theirresponsibilities motivates and helps them in developing specificobjectives they need to achieve within a specified period. Addressingtheir responsibilities and the achievement of such objectives improvetheir health condition. Improved heart failure condition isassociated with reduced readmission rates.

Desai, A. S., &ampStevenson, L. W. (2012) carried out a study on prediction andprevention of readmission. In the study, they recommended 3-phasestrategy transition, plateau, and palliative and palliation andPriorities phases. After discharge, the transition from hospital tohome has the potential of resulting in readmission. Difficultiesduring the transition phase indicate ineffective hospital, poorcoordination and communication or incomplete follow-up. Desai, A. S.,&amp Stevenson, L. W. (2012) suggested a comprehensive dischargeplanning that involves patient and healthcare provider education,collaboration, and planned follow-up program. The follow-up functionsin the identification of health issues as soon as they occur. This isfacilitated by enriching patients with information regarding suchissues. Early intervention to such issues helps in the management ofheart failure condition. The physician-based causes of readmission,lack of consultation, can be addressed by the collaboration betweenhealthcare specialists, and their involvement in patient education.

The plateau phaseemphasizes on the optimization of disease-modifying therapies. Along-term monitoring program is incorporated in this phase to checkfor early signs of worsening left ventricle filling pressures.Intensive surveillance is essential for identification and mitigationof risk factors, and it is enhanced by patient education. The phaseof palliation and Priorities addresses the health concerns amongpatients with advanced levels of the disease that early strategies inthe post-discharge trajectory cannot manage. Conditions such ashypotension and renal dysfunction make the patients less tolerant totherapies during early stages after discharge. The patients’responsiveness to diuretic therapies also reduces. This phaseinvolves making difficult end-of-life decisions about the patients inthe outpatient setting. The decisions help in coming up with feasiblepriorities of care for the patients and family. Outpatient palliativehealthcare is responsible for educating patient patients and familiesin making decisions and improve the symptom management as a way ofreducing readmission. Palliative care should be introduced during theteaching session at the time of discharge. Desai, A. S., &ampStevenson, L. W. (2012) also recommends redesigning of the heartfailure management program to include patient education and serve abroader role.

The effectiveness of various plans in the management of heart failureand reduction of readmission varies. Bradley et al. (2013)studied strategies used by hospitals to reduce rehospitalizationrate. Their study aimed at identifying such plans associated withdecreased readmission rates for heart failure patients. Hospitals aremajor stakeholders in ensuring the improvement of their patients’condition irrespective of whether they are inpatient or outpatient.Bradley et al. (2013) identified 5 strategies: partnering withlocal healthcare providers sharing discharge details with thepatient’s primary physician arranging follow-up visits beforedischarge medication reconciliation and developing follow-ups afterdischarge. A web-based survey of hospitals undertaking theinitiatives to reduce readmission was employed in the study. Dataanalysis was aided by the multivariate linear regression model.Regression analysis was appropriate for the study since it involvesthe relationship between dependent variable (readmission rate) andindependent variables (strategies and education). Since there weremore than one predictor variables the study chose the multivariateregression analysis. The regression equation generated is effectivein predicting the outcomes of implementing the hospital strategies(Gray J. R., Grove S. K. &amp Sutherland S., 2016).

From their study,Bradley et al. (2013) found out that the effect sizes of individualstrategies were limited. There is the likelihood of inconsistencyduring the implementation of the strategies due to the many factorsassociated with the readmission process including lack or inadequateeducation. However, the strategies had a more prominent effect whenthey were used together and incorporated education. 7% of thehospitals adopted all the strategies while 30% implemented more thanone strategy. Partnering with the local healthcare providers was themost effective strategy in reducing readmission for heart failurepatients during the study. The local healthcare providers play animportant role in patient education. The effectiveness of partneringwith local healthcare providers can increase when there is greatercoordination between hospital and other providers involved inreducing the readmission rates. Emergency plan is part of follow-upprogram that reduces the difficulties in coordinating a visit to thehospital and reducing readmission rates. The details of when and howpatients visit the hospital and communicating with patients todetermine follow-up needs are disseminated during teaching sessions.

According toBradley et al. (2012), despite the fact that most hospitalshave the objective of reducing readmission rates, the implementationof the recommended practices is a challenge. Hospital-basedstrategies can be categorized into three areas: quality improvementand performance monitoring, medication management, and discharge andfollow-up practices. Bradley et al. (2012) employed thestandard frequency analysis to describe their samples and independentsamples t-tests and chi-square tests to compare their samples.Quality improvement team is multidisciplinary. The multidisciplinaryteam is essential in developing a holistic approach for educatingpatients, improving their health and reducing readmission for heartfailure. Medication management practices are aimed at reducingreadmission rates through management of disease factors. Patient playhelps in mitigating disease factors through early detection andreporting of the signs of worsening health condition. This ispossible when patients are educated on the signs.

A team-basedapproach is effective in the reduction of readmission rates for heartfailure. The effectiveness of an integrated team approach isvalidated by the complex medical, social, and economic factorsassociated with high readmission rates. This approach recognizes therole of various healthcare specialists, patient, family, socialworker, and health education in reducing readmission. A 1-hourteaching session during discharge improves the clinical outcomes. Thepatient’s role is associated with adherence toguideline-recommended therapies during the post-discharge period.Gheorghiade et al. (2013) recommend the Hospital to Homeprogram that focuses on practices that aim at smooth and successfultransition. The transition program ensures that the new environmentfavors the patient’s health. Patient and family are important inbridging the hospital to home transition. Close monitoring andreporting of the general health status are the responsibility ofpatients and their family in detecting early signs of worsening heartfailure.

Information isessential in order to achieve success in any undertaking. Educationis, therefore, essential to providing patients with relevantinformation about how they can help in reducing readmission as wellas improving their health status. From the strategies used inreducing readmission discussed above, it is evident that patient needto be involved in the strategies aimed at reducing readmission.According to McCarthy D. (2016), education provides patients withinformation about their primary diagnosis, discharge medications,dietary instructions, behavioral changes, and practices to enhancetheir health and reduce readmission. McCarthy D. (2016) argues thateducation before, during and after discharge is important in reducingpatient risk factors of readmission. Patient risk factors includemedication and diet non-compliance, smoking, collaboration withhealthcare providers, and early reporting of signs of worsening heartfailure.


Heart failuremanagement is facilitated by dissemination of information from thehealthcare providers to the patients. The strategies involved in thereduction of readmission rates for heart failure revolves around thepatients and healthcare providers. Education is an important tool indisseminating relevant information about medication, follow-upprogram and recommended practices that enhance health status.Education plays and important role in reducing literacy and languagebarriers to improved health. The patient and physician factors thatcause readmission can be best addressed through education. All themembers associated with the health management practices of patientsshould be involved in the education process in order to help themunderstand their role and avoid risks factors one their side. Patienteducation is a must in order to achieve a holistic approach tomanaging heart failure. Any initiative aimed at improving patient’shealth reduces readmission rate.


Aggarwal, S., &amp Gupta, V. (2014). Causes Of Readmission InCongestive Heart Failure Patients: Analysis Of 2,536,439discharges.&nbspCirculation: Cardiovascular Quality andOutcomes,&nbsp7(Suppl 1), A238-A238.

Annema C., Luttik M. &amp Jaarsma T. (2011) Reasons for readmissionin heart failure: Perspectives of patients, caregivers,cardiologists, and heart failure nurses, Heart &amp Lung: TheJournal of Acute and Critical Care, Volume 38, Issue 5, Pages427–434s

Bradley, E. H., Curry, L., Horwitz, L. I., Sipsma, H., Thompson, J.W., Elma, M. &amp Krumholz, H. M. (2012). Contemporary evidenceabout hospital strategies for reducing 30-day readmissions: anational study.&nbspJournal of the American College ofCardiology,&nbsp60(7), 607-614.

Bradley, E. H., Curry, L., Horwitz, L. I., Sipsma, H., Wang, Y.,Walsh, M. N. &amp Krumholz, H. M. (2013). Hospital strategiesassociated with 30-day readmission rates for patients with heartfailure.&nbspCirculation: Cardiovascular Quality andOutcomes,&nbsp6(4), 444-450.

CDC, Heart Failure Statistics, retrieved from August 5, 2016

Desai, A. S., &amp Stevenson, L. W. (2012). Rehospitalization forheart failure predict or prevent?.&nbspCirculation,&nbsp126(4),501-506.

Edward K. (2012), Causes of 30 Day Readmission in Congestive HeartFailure, CAPA Conference October 2012

Gheorghiade, M., Vaduganathan, M., Fonarow, G. C., &amp Bonow, R. O.(2013). Rehospitalization for heart failure: problems andperspectives.Journal of the American College of Cardiology,&nbsp61(4),391-403.

Gray J. R., Grove S. K. &amp Sutherland S. (2016), Burns &ampGrove`s The Practice of Nursing Research: Appraisal, Synthesis, andGeneration of Evidence, Elsevier Health Sciences

Katz, A. M., &amp Konstam, M. A. (2012).&nbspHeart Failure:Pathophysiology, Molecular Biology, and Clinical Management. LWW

Mann, D. L., &amp In Felker, G. M. (2016).&nbspHeart failure: Acompanion to Braunwald`s heart disease. Philadelphia, PA :Elsevier-Saunders

White, M., Garbez, R., Carroll, M., Brinker, E., &ampHowie-Esquivel, J. (2013). Is “teach-back” associated withknowledge retention and hospital readmission in hospitalized heartfailure patients?.&nbspJournal of Cardiovascular Nursing,&nbsp28(2),137-146.