Discharge Education to Promote Self-Efficacy in Heart Failure An Education Intervention For Patients With Heart Failure

Management of congestive heart failure (CHF) continues to be a financial burden on the economy of the United States of America (USA); responsible for multiple hospital admissions and readmissions of patients with HF within thirty days post discharge. The disease has been associated with personal, physical, and economic challenges. As the population increases, the number of individuals affected with this condition is also increasing. According to the American Heart Association (2009), an estimated 400,000 to 500.000 new cases occur annually, with additional annual cost of more than $33 billion dollars added to the U.S. economy.

Discharge education, which attempts to reduce readmission rate, has become a valuable metric in the provision of health care. For effective management of heart failure symptoms, patient education is a necessity (Gruszczynski, 2010). Sara Paul (2008) discussed the importance of educating patients and their families in preventing re-hospitalization for heart failure. Evidence-based practice from the Heart Failure Society of America (HFSA), the European Society of Cardiology (ESC), the American College of Cardiology (ACC), and the American Heart Association (AHA) all recommend that heart failure patients receive individualized discharge education with emphasis placed on self-care. They also recommend that HF patients receive educational materials as part of their discharge instructions (Paul, 2008). Studies have shown that patients who been hospitalized with heart failure and received discharge education had an overall 20% improvement in compliance with their medication one year after discharge (Gwadry-Sridhar et al. 2008).

care, (discharge teaching).

Purpose

The purpose of this project is to evaluate the effectiveness of a discharge educational program in Heart failure patients to increase their knowledge of self-care and increase self-efficacy.

Introduction

Heart failure (HF) is a major and increasing health problem that affects patients, families, and communities. Approximately 5.7 million Americans have HF, with 10 per 1,000 rate of new cases reported each year after age 65 (Roger et al. 2012). Heart failure ranked third among hospital discharge diagnosis behind live births and pneumonia in 2007 (Vreeland et al.2011). The annual number of patients hospitalized with HF has increased from 800,000 to over 1 million for HF as a primary diagnosis and from 2.4 to 3.6 million for HF as a primary or secondary diagnosis (Fang and Croft, 2008). In an effort to decrease readmission rate of HF patients, institutions are seeking out ways to improve patient care (Chen et al. 2010). Reducing readmissions has become a priority and a metric of quality of care among health care providers, health plans, government, and other stakeholders.

Heart Failure is a chronic cardiac condition prevalent, especially among the elderly population, and is characterized by high mortality and hospitalization rates (Dickstein et al. 2008). HF is described by the inability of the ventricles to fill or eject blood appropriately. The heart tends to weaken over time, allowing fluids to accumulate, rendering symptoms of shortness of breath, bilateral peripheral edema, hepatic congestion, restlessness and sometimes confusion

(CDC, 2006). These symptoms occur due to the increase demand on the heart to work harder in order to ensure adequate oxygenation to the brain (Hallett, 2011). Patients may also experience an inability to perform their activities of daily living (ADL).

HF is commonly prevalent among individuals age 65 years or older with co-morbidities such as atrial fibrillation (AF), hypertension (HTN), hypotension, hyperlipidemia (HLD), diabetes (DM), gout, coronary artery disease (CAD) and renal insufficiency (AHA, 2009). Heart failure patients commonly have multiple chronic diseases and this increases the rate of readmission dramatically (Manning, 2011). In a large retrospective controlled study, the risk of preventable hospitalization increased dramatically with the number of chronic diseases. Of the many identifiable simultaneous conditions listed, depression is also a major concern, yet it is also commonly overlooked. Depression affects nearly half of all heart failure patients and disturbs their ability to both learn and maintain their medical regimen. Due to these reasons, it is imperative that patients with high risk comorbid conditions receive increased education and support (Manning, 2011).

The Centers for Medicare and Medicaid Services (CMS) announced in 2012 that it would become policy to decrease reimbursement or add penalties on institutions with high readmission rates for any cause of readmission...

Due to the proposed changes by Medicare and the Affordable Care Act, many institutions have focused on improving their performance and increasing their emphasis on decreasing readmissions; especially in the heart failure population.
Readmission rates in high risk heart failure patients can be reduced if the proper guidelines, which are supported by evidence, for discharge education is followed. If the proper guidelines are not followed, then this reduces the likelihood that patients will adhere to their treatment regimens and follow up, which is the most common reason for acute heart failure readmissions. In order to reduce these admissions, hospitals should implement a new model that delivers intensive education to high risk heart failure patients. Hospitals should support, guide, and educate HF patients as they transition from the hospital to the home (Paul, 2008).

Framework

The methodologic framework chosen to guide this project was designed by Albert Bandura. His social cognitive theory published in 1997, focused mainly on the concept of self-efficacy. According to Bandura, self-efficacy refers to the personal belief that individuals have that they are capable of learning and performing particular behaviors and is domain specific (Bandura, 1997).

The most influential source of self-efficacy information is the interpreted results of one's previous performance or mastery experience. Individual engage in task and activities, interpret the results of their actions, use the interpretations to develop beliefs about their capability to engage in subsequent tasks or activities and act in concert with the belief created (Resnick, 2009).

The concept of self-efficacy has been broadly used as a model for examining health promoting education in areas such as cardiac rehabilitation, smoking cessation, dietary modification, and compliance with medication (Kasikci, et al., 2011). Bandura postulates that the outcomes an individual expects are the results of the judgment of what he or she can accomplish, and outcome expectations are unlikely to contribute to predictions of behavior (Bandura, 1986). This theory focuses on the patients' belief in his or her ability to make changes, maintain changes, and obtain positive outcomes in their lives. One key component in the heart failure population is to monitor their daily weight. When weight gain occurs the individual should initiate action by calling their physician or increasing the dosage of their diuretic in order to reduce their weight gain. The concept of self-efficacy will be applied to this study to illicit behavioral changes.in the Heart failure patient.

Figure I. Concept of influences on perceived self-efficacy

Literature Review

Admission rate for HF patients are at an all-time high, and data is reported at 2% in 2 days, 20% at 30 days, and 50% at 6 months after discharge (Mahramus et al., 2013). Currently, heart failure has become a global epidemic with no known cure. The American College of Cardiology Foundation/American Heart association has found preventable readmissions result from failure to consistently adhere to medical, dietary, and self- care principles. They strongly recommend instructions in these areas, such as weight monitoring, maintaining a treatment plan for worsening symptoms, and making follow up appointments. Studies have shown that effective discharge education is a vital component in improving outcomes in heart failure patients Paul (2008).

. Kripalani et al. (2007), reports that the period following discharge from the hospital is a vulnerable time for patients because about half of these patients experience a medical error after hospital discharge. Patients may have an adverse drug event post discharge which represents one of the several challenges in providing high quality care as patients leave the hospital. These challenges include the discontinuity between hospitalist and primary care physicians, changes to their medication regimen, and need for closer medical follow up and adequate education for patients about medication use. There is a vital need for effective transitions of care, improvement in communication between inpatient and outpatient physicians, and effective reconciliation of prescribed medication regimen (Kripalani et al. (2007). According to the Heart Failure Society of America (HFSA), heart failure patients and their families should receive individualized education that highlights the importance of self-care. Self-care is defined as the process in which individuals perform daily activities to maintain health. HFSA further recommends that all patient education and counseling should be provided by a qualified nurse with expertise in HF management, which includes dietician and pharmacist participation (Boyde, et al., 2011).

Discharge counselling is a pivotal element and should concentrate on the key points that are of the greatest importance to the patient, such as major diagnoses, medication changes, dates of follow-up appointments, and who to contact if problems develop (Kirpalani, et al., 2007). Furthermore, the patient's understanding of the key concepts should be reinforced by hospital nurses prior to discharge.

Batty (2010) reported that the focus should be placed on educating heart failure patients during their hospitalization and at discharge, and promoting self-care management to reduce readmission. Teaching strategies should be implemented at health care centers to empower heart failure…