Hospital Discharge Education for Patients With Heart Failure: What Really Works and What Is the Evidence?

What are the barriers to self-care and how do nurses help patients overcome these barriers?Despite advances in therapy, morbidity and mortality remain high in patients hospitalized for heart failure. Although new approaches to improving the use of guideline-recommended evidence-based therapies at hospital discharge are undeniably needed,1 truly comprehensive and competent care for patients hospitalized with heart failure requires a strong focus on education of patients and their families.Education at discharge is a vital component of improving outcomes in heart failure. The institution of a structured system of patient and family education that involves a multidisciplinary team and emphasizes medication adherence, sodium and fluid restrictions, and recognition of signs and symptoms that indicate progression of disease may be as important as ensuring that patients are prescribed appropriate medical therapy. Specific topics of instruction for patients hospitalized with heart failure are listed in Table 1. Poor adherence to these instructions can lead to worsening of disease and rehospitalization. According to estimates, 54% of readmissions may be preventable, and inadequate discharge planning and education or lack of patient follow-up are common factors in readmission.3–5 Lack of compliance with medications, failure to follow a salt-restricted diet, and delays in seeking medical attention are among the primary reasons for the high rate of rehospitalization among patients with heart failure.6Patients who are not knowledgeable about their disease and their medication are at a severe disadvantage. In one study,7 the association of medication adherence and knowledge was tested in 61 patients age 50 years or older who had heart failure. Patients’ knowledge of the dosage, frequency, and indication of each of their heart failure medications and patients’ ability to open medication bottles, read labels, and distinguish tablet/capsule colors were assessed. Lower medication adherence (P = .001) and an inability to read labels (P = .002) were significantly associated with an increased number of cardiovascular-related visits to the emergency department. Patients with greater medication adherence had a mean (standard deviation) of 0.22 (0.73) visits to the emergency department per patient compared with patients who were less adherent, who had 1.00 (2.47) visits per patient. Overall, greater knowledge of, skills with, and adherence to medication were associated with fewer visits.Education of patients at discharge promotes self-care, reduces readmissions, and helps patients identify problems early, increasing the chances for intervention and improved outcomes. In this article, I discuss the importance of educating patients and their families in preventing rehospitalization for heart failure. I also address the use of performance measures to improve patients’ outcomes and methods for promoting retention of discharge instructions.Performance measures are criteria used by organizations to determine whether an organization is fulfilling its vision and meeting its patient-focused goals. These measures are standardized to evaluate hospitals and health care systems, regardless of location, in order to promote positive outcomes in patient care. Performance measures may reflect medical management of patients, but they may also assess aspects of patient care, such as education of patients and their families at discharge. The latest guidelines for management of heart failure from the Heart Failure Society of America recognize the importance of education and recommend that patients receive educational materials as part of the patients’ complete discharge instructions.8 These materials should address recommended activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if signs or symptoms worsen.2,8,9The American College of Cardiology/American Heart Association (ACC/AHA) Clinical Performance Measures for Adults With Chronic Heart Failure9 include the following inpatient performance measures for patients with heart failure: discharge instructions, evaluation of left ventricular systolic function, angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker for left ventricular systolic dysfunction, adult smoking cessation advice/counseling, and anticoagulant at discharge for patients with atrial fibrillation. The guidelines recommend that the clinical care team collect data and review compliance with these measures on a routine basis, look for changes, and adjust practice patterns as necessary to improve performance. The performance measure of discharge instructions and its components are shown in Figure 1.9The Joint Commission evaluates 4 performance measures for patients with heart failure that are similar to those of the ACC/AHA: discharge instructions (HF-1), assessment of left ventricular function (HF-2), use of angiotensin-converting enzyme inhibitors in patients with left ventricular systolic dysfunction (HF-3), and smoking cessation counseling (HF-4). These Joint Commission core measures require that patients with heart failure receive written instructions or educational material at discharge that will adequately address all of the components mentioned in the guidelines.10 The intention is that through use of these performance measures, the quality of cardiovascular care will be improved.11 However, conformity with these indicators among health care providers is not guaranteed.In 1997, medical records from 9 hospitals were retrospectively reviewed to determine the percentage of patients who receive the quality of care indicators derived from the clinical practice guidelines of the Agency for Health Care Policy and Research. A total of 1623 hospitalizations for heart failure were reviewed; the mean frequencies of documentation of counseling about medications, weight, diet, exercise, and smoking cessation were as follows:Medications: 97% (range, 95%–98%)Weight: 6% (range, 3%–12%)Diet: 70% (range, 58%–94%)Exercise: 61% (range, 26%–81%)Smoking cessation: 14% (range, 0%–33%)The variability of counseling between hospitals was high, and documentation may not reflect what was actually practiced.12 The documentation may or may not have reflected the extent of the counseling. How the information was conveyed and the depth of the patient’s understanding of the information were not documented. More recently, data from 81 142 admissions of patients with heart failure in the Acute Decompensated Heart Failure National Registry (ADHERE) were analyzed to determine rates of conformity with the 4 core performance measures from the Joint Commission.13 The median rate of conformity with discharge instructions (HF-1) was only 24% (range, 0%–99%), and the median rate of conformity with HF-4 (counseling for smoking cessation) was 43.2% (range, 0%–100%). A substantial gap in overall performance is apparent among hospitals. The establishment of educational initiatives and quality improvement systems to reduce this variability may substantially improve care.The relationship between current ACC/AHA performance measures for patients hospitalized with heart failure and clinical outcomes was investigated in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF), a registry and performance improvement program for patients hospitalized with heart failure. Only use of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker at discharge was associated with a reduction in mortality or rehospitalization at 60 to 90 days after discharge.14 Trials comparing conventional management of heart failure with management programs that included counseling of patients about diet, exercise, medications, and monitoring have shown that disease management programs can reduce hospital stays and improve functional status.15 However, these programs often involve outpatient programs, such as clinics or home visits, that are beyond those normally assessed in the ACC/AHA performance measure on discharge instructions. It is unclear whether the discharge instruction performance measure as recorded in the hospital reflects whether the patients did or did not receive each defined component of education. Patient education may be documented in the medical record even if the education was cursory and allowed little time for the patient to absorb and retain the information.15 Conversely, many patients and their families are not ready to learn at the time of diagnosis, regardless of how thorough the instructional session may be. Extensive education may be better absorbed when a patient is in a stable condition and has adapted to living with heart failure.16In the analysis of data from OPTIMIZE-HF, the discharge instruction performance measure did not have an effect on mortality or rehospitalization at 60- to 90-day follow-up.14 Fonarow et al14 concluded that current performance measures related to heart failure, other than the prescription of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker at discharge, have little effect on patients’ outcomes shortly after discharge. Another OPTIMIZE-HF analysis17 specifically addressed education of patients; researchers assessed the characteristics of patients who did and did not receive the full set of components from the Joint Commission process-of-care performance measure (HF-1) and then analyzed whether receipt of this measure was predictive of other elements of discharge planning. Credit for the core measure (HF-1) was not given unless all 6 components (activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if signs or symptoms worsen) were documented. Despite recommendations that complete instructions be given to patients with heart failure before hospital discharge, both the process intervention tools to facilitate HF-1 and HF-1 itself were underused. Delivery of the full set of HF-1 components was significantly more likely in the 46% of patients who received process improvement tools.17 Additional measures and/or better methods for identifying and validating performance measures related to heart failure may be needed to improve care and outcomes of patients with heart failure.14Data suggest that in practice, discharge education is not emphasized as an essential component of optimal care for patients with heart failure. A retrospective review18 of medical records at a large, inner-city teaching hospital of 104 patients with heart failure showed that discharge counseling about medication adherence, restricted sodium intake, and the importance of weight monitoring was provided to only 50%, 48%, and 9% of patients, respectively. The large number of patients who are discharged without receiving education may represent important missed opportunities to decrease morbidity and mortality.Critical pathways and in-hospital instructional tools may improve the provision and quality of discharge education. The AHA Get With the Guidelines heart failure program is a hospital-based quality improvement program implemented in 2001 to promote the use of up-to-date guidelines for treating patients with heart disease and stroke. Currently, more than 1300 hospitals are enrolled in the program.19 A key component is the Patient Management Tool, a Web-based interactive assessment and reporting system that tracks treatment and facilitates evidence-based medicine. This tool helps caregivers manage patients’ care by providing (1) drop-down reminders of current guidelines at key data points, (2) prescriptive medication reminders specific to the patient’s disease, (3) printed disease-specific patient education materials before discharge, and (4) automated patient dismissal notes and referring physician letters.20 An example of the discharge instructions is shown in Figure 2.19 This tool includes education as part of the overall discharge checklist.Although many hospitals are adapting the tools from the Get With the Guidelines heart failure program into care, the presence of tools alone is not enough to guarantee evidence-based practices. In a study21 of how core measures from the Joint Commission are applied at a university hospital, availability of standardized order forms, computer discharge instructions, and education materials did not lead to improvement in scores for core measures. The scores improved only after the appointment of a dedicated heart failure physician and nurse practitioner who used the standardized forms, computer discharge instructions, and the education materials. Use of the dedicated heart failure team led to quick and sustained improvements.21In addition to verbal information, a combination of educational materials may enhance a patient’s ability to absorb information. Books, newsletters, videos, CDs, Web pages, and computer-based programs augment the learning process and offer further opportunities for education at patients’ convenience after discharge from the hospital. Many patients will need repeated education through follow-up telephone calls, newsletters, educational bulletins, or support groups because of the volume of information that is given at the time of hospital discharge.Educational tools must be a component of multidisciplinary care provided to heart failure patients.22 The team approach to education of patients improves patients’ outcomes. In one study,23 an intervention group (n=44) of patients received education from a cardiac nurse educator, a registered dietitian, and a physical therapist, along with corresponding written materials. These patients received an initial visit, as well as a follow-up visit from the nurse educator, dietitian, and physical therapist during the patients’ hospitalization. Discharge planning was coordinated with home health nurses, who reinforced the instructions given in the hospital. Patients in the control group who received “usual care” did not have access to the nurse educator, did not automatically receive dietary and physical therapy consultations, did not have routine telephone contact after discharge, and did not receive home visits from nurses trained in management of heart failure. Hospital readmission rates were 4 times higher in the group of patients who received usual care (n=77) than in patients in the intervention group. Additionally, patients in the control group required nearly 50% more skilled nursing care visits and more than twice as many home health aid visits than did the patients in the intervention group. The 6-week cost savings for the intervention group was $67 804.Successful management of heart failure often requires major lifestyle adjustments, such as modifications in diet and activities, compliance with a complex medication regimen, and the need to assess and monitor signs and symptoms. Despite best efforts at education, helping patients understand all of the complexities of their disease and therapy may be difficult. Many patients have low levels of knowledge of their disease and lack a clear understanding of heart failure and self-care. In a study24 of knowledge level in patients with heart failure, although two-thirds of the patients reported receiving information or advice about self-care from health care providers, 37% of patients knew “a little or nothing,” 49% knew “some,” and only 14% knew “a lot” about heart failure. Approximately 40% of the patients did not recognize the importance of weighing themselves daily, and 25% did not appreciate the risk of consuming alcohol. Although 80% of the patients knew they should limit the amount of salt in their diet, only one-third regularly avoided salty foods.Understanding patients’ barriers to learning may enable nurses to tailor educational approaches accordingly. Simply communicating a therapeutic plan is different from successfully educating patients and their families. Patients and their families should be treated as partners in learning, not as pupils. If patients feel engaged in the discussion and their learning needs are assessed, they may feel that the information is more pertinent to their situation. Teaching sessions should not be a 1-way communication session, but should engage patients in identifying their learning needs.25 Nurses who teach patients should receive training to ensure that the educational information taught is consistent among all staff members. If the information varies among the staff, patients and their families can become confused.Hospitalized patients may be anxious about their disease and may be concerned about their ability to perform self-care once they are home. Plenty of time should be allowed for patients to ask questions as they digest the new information. Paper and pencil should be available at the bedside for patients to write down questions as they think of them. Patients and family members should be given a telephone number that they may call to speak to a nurse if they have any questions or problems after discharge. Knowing that they will receive follow-up home visits or telephone calls may allay their anxiety and fears and allow patients to absorb information more readily.An articulate and fluent translator should be included in teaching sessions when patients do not have command of the English language. The translator should be available if a patient has questions later. Cultural differences may impede the learning process. Dietary preferences may be somewhat different for patients of different cultures, and flexibility should be given to allow patients to maintain their cultural differences yet remain within healthy parameters. If possible, a dietitian should be involved to help patients select foods that are acceptable to the patients’ palate but low in sodium. Foods such as soy sauce or tomato salsa are high in sodium, and every effort should be made to find low-sodium substitutes.Educational interventions should be specifically tailored for patients and their families and should target their particular barriers to learning, such as functional and cognitive limitations, misconceptions, low motivation, and low self-esteem.25 The reasons for difficulty in following a prescribed regimen are multi-factorial, but possible barriers to self-care and optimal adherence may include a complex medication regimen that is confusing to the patient, cognitive impairment that makes it difficult for the patient to remember instructions, or the lack of motivation to follow discharge instructions.Patients with heart failure are often discharged with complex medication regimens.26 Despite the best intentions of practitioners, patients’ understanding of the reason for each medication may be low, and their ability to follow therapeutic instructions may be limited. Noncompliance can be as high as 64% for medication and 22% for diet.27 In a retrospective study28 of 1031 admissions for heart failure, noncompliance with medications and diet led to sodium retention and was the causative factor in 55% of the admissions. One-third of the patients were noncompliant with medications, diet, or both. In a study29 of 220 patients with multiple hospital admissions, the rates of noncom-pliance with medication, smoking cessation, and abstaining from alcohol were as high as 64%, 69.5%, and 71%, respectively. Compliance may be increased by improving patients’ understanding of the importance of the therapy and by streamlining therapy through the use of once-daily agents to reduce the complexity of pill-taking regimens.30A patient’s ability to understand, remember, and apply what he or she was taught at discharge is another large barrier. Elderly patients often have comorbid conditions in addition to heart failure that can make it difficult to understand and comply with therapy. The incidence of cognitive impairment among patients more than 65 years old who have heart failure is high compared with the incidence in younger patients,31 indicating that education of elderly persons is a challenge. Cognitive impairment may include short- or long-term memory loss, dementia, or attention deficit. In a study of recall of recommendations and adherence to advice among patients with heart disease, Kravitz et al32 found that patients who did not recall the instructions had a much greater risk of noncompliance with medications and diet than did patients who remembered the instructions. Interestingly, patients whose physicians counseled them about lifestyle changes and medications were significantly (P<.05) more likely to recall the recommendations during a follow-up telephone interview. Unfortunately, even among patients who recalled the advice, the non-compliance rate with smoking cessation remained high.Cline et al33 examined the extent of noncompliance with prescribed medication in elderly patients with heart failure and reviewed the extent to which patients recalled information given about it. All patients received standardized verbal and written information about their medication, but only 12 (55%) could correctly name what medication had been prescribed, 11 (50%) were unable to report the doses prescribed, and 14 (64%) could not remember what time(s) the medication was to be taken.To overcome memory issues, we must ensure that all instructions and advice verbally communicated to patients are also provided in a written format that patients can take with them to share with family members and refer to later. Family members should be included in the educational session so that they hear the information and can reinforce the instructions once the patient is at home. If the patient’s friend or family member who assists in preparing the weekly medications cannot attend a teaching session or an appointment when medication changes are discussed, a note explaining the changes should be sent home with the patient. Even better, a telephone call to the person who oversees the patient’s medications will prevent confusion or medication errors. If a patient with cognitive impairment does not have a family member to assist with medications, it may be helpful to contact the patient’s local pharmacist, home health nurse, or physical therapist to clarify changes in medication. Any health care professional who has regular contact with a patient can help in evaluating whether the patient is taking the medications correctly.A list of medications and when to take them should be in large print, and patients should be instructed to place that list prominently in the area where daily medications are stored. Weekly pill containers with 3 compartments per day for morning, afternoon, and night doses help patients remember if they have taken their medications earlier in the day. Refrigerator magnets with information about signs and symptoms of worsening heart failure and the telephone number that the patient should call if those symptoms occur can serve as easily accessible daily reminders. Pictures of foods to avoid, such as high-sodium foods, should be available for patients to keep near the patients’ grocery shopping list. Follow-up telephone calls or home visits may help patients remember and follow important discharge instructions. Charts that specify the time of day for each medication dose, either with the use of a clock depicting the time or with doses scheduled around meals, may enhance patients’ ability to take pills at the correct time of day (Figure 3). Pictures of each pill, which can be found in many medication books or online, can help patients identify their medications and may reduce medication errors.Patients’ difficulty in following recommendations for diet, exercise, and smoking cessation may be due to lack of motivation and/or self-control. An increase in knowledge is not necessarily accompanied by concomitant changes in compliance behaviors. Poor physical capacity, fatigue, and depression and anxiety are common among patients with heart failure,25 and all these factors can lead to lack of motivation and low interest in learning how to perform self-care. Ni et al24 reported that although most elderly patients with heart failure confirmed the importance of restricting sodium intake and limiting fluid consumption, less than half reported always avoiding salty food, and an equally low percentage did not closely monitor daily weight or fluid intake. This type of noncompliance indicates the need for education about the importance of dietary restrictions and potential consequences of nonadherence. Effective communication between patients, their families, and the health care team may help minimize the difficulties associated with dietary restrictions.Health care providers may think that a broad statement such as “remove salt from your diet” or “weigh yourself every day” is sufficient education. But important aspects of communication are left out of instructions like these, such as why the change is important, specific details, and examples of how to go about these lifestyle changes.2 The poor taste of low-sodium food may also be a large barrier.34 Eliciting the assistance of a clinical dietitian for strategies that help patients and caregivers find special food items, plan menus, adjust recipes, and alter the preparation of food can be of great benefit.2,35 Helping a patient plan meals and prepare a grocery list with appropriate low-sodium foods will offer “real-life” ideas and suggestions. Cookbooks and Web sites with low-sodium recipes can be helpful to patients and their spouses as they plan meals (Table 2). Lists of foods to avoid, foods to enjoy in moderation, and foods that are within dietary guidelines should be readily available for patients, along with lists of substitutes or alternatives to high-sodium foods.Although smoking can contribute to increased risk for multiple hospital admissions, most patients lack motivation to stop smoking cigarettes.29 Despite medical counseling and awareness that smoking induces signs and symptoms of heart failure, patients who have been hospitalized often continue to smoke. Although smokers may be instructed to quit, they may not be provided with the proper counseling or referral to a program or technique that would assist them.36 Education and counseling sessions to promote behavior change, referral to smoking cessation programs, and recommendations to use nicotine replacement substances may be key to helping patients with nicotine addiction. Medications that promote smoking cessation, such as bupropion or varenicline, should be used with extreme caution, and patients should be closely monitored during therapy.Similar techniques should be used in patients who are at risk for continuing to consume alcohol after discharge. Results of studies24,37 on alcohol use among patients with heart failure indicate that 25% to 40% of patients with heart failure do not understand the risks of alcohol consumption. Efforts to educate patients about the detrimental effects of alcohol on cardiac function should be reinforced, and resources should be provided that can facilitate alcohol-withdrawal efforts. Support group therapy and alcohol cessation programs may offer support to patients who find it difficult to stop consuming alcohol.Motivation for making behavioral lifestyle changes may be low in patients who are not ready to commit to making those changes. Despite education on lifestyle changes that are necessary when living with heart failure, many patients are not ready to learn how to manage their illness. Some patients are more prepared than others to hear the information and make the appropriate lifestyle changes. For that reason, it is important to determine each patient’s level of readiness to make lifestyle changes and then individualize the educational sessions to the patient’s level of readiness.38,39 For instance, if a patient states that he or she does not wish to follow a low-sodium diet, simply handing the patient written information on that topic may have limited benefit. However, exploring patients’ dietary preferences with them and tailoring recipes and spice suggestions may offer appealing ideas to patients. If a patient enjoys foods cooked with garlic salt, perhaps a combination of garlic powder and onion powder will be pleasing to the patient. Patients should be encouraged to experiment with low-sodium spices that suit their personal tastes.The methods and delivery of patient education are varied and may be important to outcomes. Education of patients consists of 5 steps, beginning with assessment of a patient’s knowledge, learning abilities, learning styles, cognitive level, and motivation.25 Next, the patient’s learning needs and barriers to learning must be determined. The third step includes discussion with the patient to plan the educational intervention and set goals. In the fourth step, the education and information is delivered to the patient and the patient’s family as planned. The last step includes evaluation of the learning process. Strategies that fit with the patient’s learning styles, cognitive level, and motivation by using tailored interventions offer a directed way to enhance compliance among patients.6,7,23,25–27,29,30,34,40–45 Practical ideas for improving patients’ adherence are listed in Table 3. Nurses are crucial to the success of education and can increase the probability of optimal discharge instruction and better outcomes by using better education strategies.23Patients with heart failure recognize the importance of discharge education. When asked about what information is important, patients ranked information on medication and signs and symptoms as most important, followed by general education about heart failure, risk factors, prognosis, activity, psychological factors, and diet.46–48 The method of teaching patients varies from patient to patient, depending on multiple factors. Patients’ educational level dictates their ability to comprehend written information, and poor visual a