Effectiveness of a Telemonitoring and Patient-Centric Health Coach Intervention for Adult Patients with Heart Failure: A Quality Improvement Project in Transitional Care

Background: Telemonitoring interventions to prevent readmissions in patients with heart failure (HF) have shown inconsistent results in their effectiveness on HF-related and all-cause rehospitalization. Interventions geared toward early identification of HF symptoms in concert with improved care coordination and enhanced patient self-care may help to prevent unplanned hospitalizations in patients with HF. The Theory of Heart Failure Self-care provided the framework to understand and direct a combined telemonitoring and patient-centric health coach intervention (Tele-HC).
Objective: The purpose of this quality improvement project was to evaluate the outcomes of a Tele-HC intervention designed for older adult patients with heart failure in a community hospital setting.
Methods: The outcomes evaluation used a descriptive, cross-sectional observational design for the readmission rates. A one-group pretest-posttest design was used to measure self-care outcomes. Predictive models were tested using correlation and regression analysis.
Results: The 30-patients were primarily Caucasian, female with a mean age of 77.5 years. The majority of patients had HF with an ejection fraction ≤ 40%, NYHA class II or III symptoms, and received appropriate medical therapy. Health literacy was adequate in the sample. The 30-day all cause readmission rate was 6% with no patients being re-hospitalized for decompensated HF. Patient self-care scores improved with all three categories reaching statistical significance (p < .0001). Patients received mean of two touches daily during the first two weeks and a mean of three touches every two days for the remainder of the study. A significant relationship existed between the number of touches during the first two weeks and improvement in self-care maintenance scores
(p =.009). The number of touches moderately predicted changes in these scores
(r = .426, p =.019). No direct correlation was drawn between touches and readmission rate, due to the data being skewed in favor of the intervention.
Conclusion: Strategies that engage patients as partners in their self-care and leverage technology appear to reduce readmissions and improve self-care outcomes.