European Journal of Cardiovascular Nursing

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Components of heart failure management in home care; a literature review

Tiny Jaarsma, Maaike Brons, Imke Kraai, Marie Louise Luttik and Anna Stromberg
Eur J Cardiovasc Nurs 2013 12: 230 originally published online 15 June 2012
DOI: 10.1177/1474515112449539

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49539 CNU12310.1177/1474515112449539Jaarsma et al.European Journal of Cardiovascular Nursing

EUROPEAN
SOCIETY OF
Review Article CARDIOLOGY

European Journal of Cardiovascular Nursing

Components of heart failure 12(3) 230241

The European Society of Cardiology 2012
Reprints and permissions:
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DOI: 10.1177/1474515112449539
a literature review cnu.sagepub.com

Tiny Jaarsma,1,2 Maaike Brons,2 Imke Kraai,2

Marie Louise Luttik2,3 and Anna Stromberg1

Abstract
Background: Patients with heart failure (HF) need long-term and complex care delivered by healthcare professionals in
primary and secondary care. Although guidelines on optimal HF care exist, no specific description of components that are
applied for optimal HF care at home exist. The objective of this review was to describe which components of HF (home)
care are found in research studies addressing homecare interventions in the HF population.
Methods: The Pubmed, Embase, Cinahl, and Cochrane databases were searched using HF-, homecare services-, and
clinical trial-related search terms.
Results: The literature search identified 703 potentially relevant publications, out of which 70 articles were included. All
articles described interventions with two or more of the following components: multidisciplinary team, continuity of care
and care plans, optimized treatment according to guidelines, educational and counselling of patients and caregivers, and
increased accessibility to care. Most studies (n=65, 93%) tested interventions with three components or more and 20
studies (29%) used interventions including all five components.
Conclusions: There a several studies on HF care at home, testing interventions with a variety in number of components.
Comparing the results to current standards, aspects such as collaboration between primary care and hospital care,
titration of medication, and patient education can be improved.

Keywords
Continuity of care, evidence based, heart failure, home care, review
Received 20 December 2011; revised manuscript accepted 4 May 2012

Background continuity.37 Clinical continuity of care can be defined as a

Patients with heart failure (HF) constitute a large group
within health care worldwide. The prevalence of sympto-
matic HF is estimated to 2% of the population, approxi-
mately 15 million in Europe.1 The mean age of HF patients
is around 75 years and HF is a leading cause of hospitaliza-
tion for elderly patients at high healthcare costs.1 Patients
with HF often need complex care due to their older age,
poor social support, cognitive decline, comorbidities, and
polypharmacy.2 In addition, the prognosis of HF patients is
poor and half of the patients die within 45 years after their
diagnosis.1 All these aspects are challenges when planning
HF care. A growing number of HF patients will be in need
consistent and coherent approach to the management
of health conditions that is responsive to patients needs
including a seamless transition over time between various
healthcare providers in different settings.3,59 The concept
of continuity of care has been linked to quality of care and
has especially been advocated in the management of
chronic conditions such as HF.
Home-based interventions have been found to reduce
mortality4,10 and morbidity11 and preserve physical and
1Linkping University, Norrkping, Sweden
2University of Groningen, Groningen, The Netherlands
3University of Applied Sciences, Groningen, The Netherlands

of lifelong care with regular follow up to achieve and main-

Corresponding author:
tain optimal treatment and support self-care management. Tiny Jaarsma, Department of Department of Social and Welfare Studies
Ideally, long-term follow up should be integrating the (ISV), Linkping University, 601 74 Norrkping, Sweden.
primary and secondary care interfaces to facilitate clinical Email: tiny.jaarsma@liu.se

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Jaarsma et al. 231

Table 1. Bibliographic search strategy.

Database Access date Search strategy No of articles

Pubmed 6 April 2011 ((Heart Failure[Mesh] OR heart failure[TIAB]) AND (Home Care 181
Services[Mesh] OR home care[TIAB]) AND (Clinical Trial [Publication
Type] OR Epidemiologic Study Characteristics as Topic[Mesh] OR clinical
trial OR controlled trial OR random* OR case-control OR cohort OR
observational)) NOT (heart transplant*[tw] OR cardiac transplant*[tw] OR
editorial[Publication Type] OR review[Publication Type] OR review literature
as topic[MeSH Terms] OR Comment [Publication Type]) Limits: English
Embase 6 April 2011 clinical study/exp OR clinical study OR cohort analysis/exp OR cohort 254
analysis OR observational study/exp OR observational study OR cohort
OR case-control OR clinical trial/exp OR clinical trial OR controlled
trial/exp OR controlled trial OR random* OR observational AND (home
care/exp OR home care:ti OR home care:ab) AND (heart failure/exp
OR heart failure:ti OR heart failure:ab) AND [english]/lim NOT (letter/
exp OR conference paper/exp OR editorial/exp OR review/exp)
NOT (cardiac transplantation/exp OR cardiac transplantation OR heart
transplantation/exp OR heart transplantation) AND [embase]/lim
Cinahl 6 April 2011 ((MH Heart Failure, Congestive+) OR (TI heart failure) OR (AB heart 91
failure)) AND ((MH Home Health Care+) OR (TI home care) OR (AB
home care)) AND ((MH Clinical Trials) OR (MH Nonrandomized Trials)
OR clinical trial OR controlled trial OR random* OR cohort OR case-
control OR observational) NOT ((MH Literature review+) OR letter OR
editorial OR cardiac transplant* OR heart transplant*)
Cochrane 6 April 2011 ((Home Care Services[MeSH] OR home care[TIABKW]) AND (Heart 177
Failure [MeSH] OR heart failure[TIABKW])) NOT (cardiac transplant*) OR
(heart transplant*)

mental health6 in patients suffering from HF. HF clinics are
common in several European countries7 and, also, in pri-
mary care the number of specialized HF clinics is increas-
ing.5 However, HF clinics are often situated at the hospital
or at a primary healthcare centre.7,12 When exploring the
prevalence of home-based care in Europe, we found that
very few of the HF management programmes offered home
care and that collaboration across the primarysecondary
care interface was unsatisfactory.7
In a meta-analysis on the effectiveness of disease man-
agement programmes, the authors separated the multidisci-
plinary HF clinics from the programmes that provided
specialized follow up in a non-clinical setting. They con-
cluded that programmes in a home-based setting were
found to be as effective in reducing mortality and rehospi-
talization as the clinic setting. However, no information
was available on the specific components of the homecare
intervention. In general, no specific description of compo-
nents for HF care at home exists. In developing and further
testing of disease management programmes in home care,
an overview of the components that are included in these
programmes can be helpful. Therefore the purpose of this
review was to describe which components of HF (home)
care are found in research studies addressing homecare
interventions in the HF population. In this study, home care
is defined as health care or supportive care provided in the
home by licensed healthcare professionals.
Materials and methods
Search strategy
A comprehensive search was conducted through the Pubmed,
Embase, Cinahl, and Cochrane databases of medical litera-
ture published until April 2011 with a customized search
strategy for each database. The search strategy consisted of
HF- and homecare-related search terms (Table 1). After con-
sultation with literature search experts from the university
library, we tailored the search strategy to each database to be
as specific as possible. We specified our search strategy by
including Mesh terms, specific terms in title and abstract, no
review and editorials, type of trials, and language English
and excluding transplantation. Not all databases however
allowed use of MESH terms and therefore, in these cases
search engine specific terms were used (e.g. exp in Embase).
The thesaurus of each database was also different so the
term home care needed to be adapted per database.
Selection of articles
The literature search identified 703 potential relevant pub-
lications: Pubmed (n=181), Embase (n=254), Cinahl
(n=91), and Cochrane (n=177). Several articles (n=236)
were simultaneously present in more than one database.
To be included in the present review, publications were
assessed by two independent reviewers using the following

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232 European Journal of Cardiovascular Nursing 12(3)
703 potential relevant publications
Duplicated publications (n=236)
Flowchart of inclusion
467 potential relevant publications
Publications excluded (n=379)
Palliative care or end of life care (n=21)
Not addressing patients but caregivers/professionals (n=24)
Addressing medical agent, instrument or only exercise (n=68)
Addressing predictors or relationships (n=25)
Addressing design only (n=5)
Pilot studies (n=32)
Beta testing of equipment (n=4)
No HF patients or no primary HF population (n=87)
No home care (n=1)
Not original papers (n=51)
Not addressing an intervention (n=43)
Not published in English (n=8)
Age < 18 years (n=8)
Not peer reviewed (n=2)
18 secondary publications (describing the same study)
70 publications
Figure 1. Flowchart of inclusion.
inclusion criteria: The articles had to: (1) describe a clinical
trial in a homecare setting; (2) describe studies performed
in patients with HF with an age over 18 years; (3) be pub-
lished in English; and (4) be original, full-text articles pub-
lished in peer-reviewed journals. Exclusion criteria were:
(1) addressing end-of-life care only; (2) not caring for HF
patients; (3) not addressing a programme of disease man-
agement; and (4) not reporting on an intervention. In total,
379 articles were excluded: 21 articles assessing palliative
care or end-of-life care; 24 articles not addressing patients
but caregivers or professionals; 68 articles addressing a
medical agent, an instrument, or only exercise and not a
disease management programme or other components (e.g.
meditation, relaxation); 25 articles addressing predictors or
relationships; five articles addressing design of the study
only; 32 articles addressing pilot studies; four articles per-
forming beta-testing of equipment; 87 articles not address-
ing patients with HF or did not consist of a primary HF
population; one article not describing a homecare interven-
tion; another 112 articles not fulfilling the inclusion crite-
ria; and 18 papers describing the same study. Figure 1
shows the flowchart of inclusion.
Assessment of articles
For the purpose of describing components of the homecare
programmes, all articles were read and organized in a table
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describing the following components.13 The list of compo-
nents was derived partly from earlier described key compo-
nents and guidelines:1,13
multidisciplinary team
continuity of care and care plans
optimized treatment according to guidelines
educational and counselling of patients/families/
caregivers
increased accessibility to care.
We also added a separate column other components on
our data analysis sheet.
Results
In total, 70 articles were summarized in a table describing
components of home care in HF patients (see Appendix 3).
Most studies (n=65, 93%) tested interventions with three
components or more. Only five (7%) studies tested inter-
ventions with two components and 20 studies (29%)
included all five components in their intervention. We did
not find additional components. The following paragraphs
describe the findings per component within the different
studies.
Multidisciplinary team
Most studies (n=69, 99%) reported care provided by a
multidisciplinary team but a great deal of heterogeneity
regarding the professionals involved was described.
Collaboration between primary care and secondary care
was scarcely reported.
Team members. In almost all studies, nurses played a
coordinating or leading role. They were described as
homecare nurses, hospital nurses, HF nurses, cardiac reha-
bilitation nurses, research nurses, practice nurses, and/or
district nurses, but description of the specialization or clini-
cal background were lacking. Almost all programmes also
had physicians involved, which could be cardiologists, and/
or primary care physicians or other specialists such as geri-
atricians or internists. Two studies specifically reported
collaboration between the primary care physician and car-
diologist.14,15 In one study, the team existed of a trained
doctors assistant and a primary care physician.16 In another
study, the team existed of a physician, physiotherapist,
ECG technician, and a psychologist. In these teams, nurses
were not involved.17
Additionally, other professionals (psychologist, dieti-
cian, physical therapist, social worker, pharmacist) were
involved in the programmes,1823 mostly as member of the
multidisciplinary team or occasionally as the main provider
of an intervention (e.g. a pharmacist).24,25
Jaarsma et al. 233
Education of the team members. In general, the specific
training of the team members was not well described in the
manuscript. Specific training for nurses was mostly
described in general terms such as for example: as a spe-
cific HF programme based on AHCPR guidelines or
trained nurses26 or advanced practice nurse27 or a one
day training course or Nurses underwent brief training
programme regarding problems and treatment options
associated with this particular group of patients.11,28,29 In
one study, nurses participated in an interactive practitioner
training as well as role playing and audio taping, to help the
nurse increase their skills in communicating with and moti-
vating their patients to adherence to treatment instructions.29
In another study, advanced practice nurses participated in a
2-month orientation and training programme focused on
developing their competencies related to detection of dete-
rioration in HF in elderly patients, how HF is complicated
by common comorbid conditions, and optimal therapeutic
management.19 Furthermore, the advanced practice nurses
participated in a training programme focused on educa-
tional and behavioural strategies in the home to address
patients and caregivers unique learning skills.19 For other
healthcare providers, specific training even less well
described such as the health coaches underwent a highly
scripted training process or the study pharmacist had
combined experience as hospital and community pharma-
cist, had a doctor or pharmacy degree and completed a one-
year clinical residency in home care.
Continuity of care and care plans
Several studies introduced a specific care plan or clinical
pathways for the study.11,22,2951 In total, 47 (67%) of the
studies described a care plan as part of their intervention.
From the description in the publication, it was not always
clear if the care plan was integrated between primary and
secondary care. However, in other studies, specific descrip-
tions of the goals and responsibility of the care plan were
described.30,32 In one study, the hospital physician provided
a written management plan regarding pharmacological
treatment and monitoring to the primary care physicians.35
In another study, the intervention specifically focused on
the transition of care with improved intersector linkages
using a joint care plan.43 In that study, linkages were cre-
ated by including a nursing transfer letter, a telephone out-
reach, a notification of who was responsible for the care,
and a patient-held documentation.
Optimized medical treatment according to
guidelines
Optimized treatment according to guidelines (e.g. medica-
tion, implementation of devices) was reported in 31 (44%)
of the 70 studies. Optimization of drug treatment was
more explicitly described as one of the components of the
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intervention programme in 23 (33%) of the 70 studies.
It was carried out by health professionals in the hospital
(14 studies)14,19,21,28,34,36,41,5358 or by primary care nurses or
physicians within primary care (six studies).20,25,37,46,51,52 In
three studies, it was not clear who performed the optimiza-
tion of the medications.40,59,60
Drugs were prescribed and titrated to optimal doses
either following guidelines and protocols or following a tai-
lored recommendation for optimization of medical therapy
with individual titration plan. Some studies reported meth-
ods for adjustment of diuretics and recommendations for
discontinuation of inappropriate medications.21,25,37,46,52,59,60
Methods of drug titration and adjustment of diuretics. A few
studies described their method used for the titration of HF
medication.14,19,20,28,33,34,37,46 One study reported that the
nurse evaluated the data transmitted by the patient (i.e.
weight, blood pressure, heart rate) and subsequently titrated
medication.34
Other studies described nurses following an established
protocol in close collaboration with the family physician or
cardiologist, especially when it was necessary to start new
treatment or adjust existing medication.14,17 In these studies,
no precise description of the protocols was given. In another
study, all patients were given a management plan by the
investigator that described the pharmacological treatment
they should receive, in what order, and how it should be
monitored.38 The pharmacological treatment focused on
appropriate doses of angiotensin-converting enzyme inhibi-
tors and beta-blockers. If severe symptoms were present, an
aldosterone antagonist was prescribed according to regional
guidelines. The study consists of three different strategies;
usual care, nurse telephone support, and home telemonitor-
ing.38 In three studies, it was mentioned that strict treatment
protocols or accepted guidelines were used for titration of
medication but no details on the content of the protocols
were provided in the articles.56,58,60
The methods for adjustment of diuretics were reported
in four studies.20,28,31,46 In one study, investigators devel-
oped a set of algorithms based on accepted national CHF
guidelines including the appropriate use of potassium spar-
ing diuretics, to help determine the adequacy of medication
regimes.46 Another study reported the application of infu-
sion of diuretics in case of an emergency by the supervising
physician.28 One study described an intervention where,
after liaison with the primary care nurse and the cardiolo-
gist, the cardiac nurse arranged a flexible diuretic regimen
in response to the patients symptoms and weight.20 Another
study described an intervention where the nurse informed
the patient about how to modify the dose of diuretics with-
out waiting for a medical visit.31
Responsible for medication adjustment. In five studies, the pri-
mary care physician was reported being responsible for the
adjustment of HF medication. Nine studies reported
234 European Journal of Cardiovascular Nursing 12(3)
the cardiologist as the supervisor of drug prescription and
titration of drugs. In a few of these studies, the (community)
nurse made adjustments of diuretics, angiotensin-converting
enzyme inhibitors, or beta blockers under the supervision of a
cardiologist.41,59 In one study, the cardiologist in difficult
cases (multiple comorbid conditions or concurrent medica-
tions) provided expert advice to the nurse by telephone.54 In
another study, optimization of medical therapy was per-
formed by the HF cardiologist specialized in HF after consul-
tation with the patients family and primary care providers.55
Education and counselling of patients/
families/caregivers
Education was described in 61 (87%) of the 70 studies. In
these studies, education was mostly part of a larger
programme.
Provider and methods. In most studies, the nurse provided
patient education to patients (and families). In three
programmes, other healthcare workers (e.g. pharmacists)
provided patient education.24,25,61
Almost all programmes used verbal educational strate-
gies. In several educational programmes, booklets, diaries,
education maps, reminder cards, pamphlets, or brochures
were applied. Other strategies included a remote video
system, email reminders,44,62 educational modules via
telehealth, or motivational messages.63 Group training was
mentioned in one programme.55
Partners, family, or other caregivers when providing
patient education were included in patient education in
seven programmes. 19,23,32,33,60,64,65
Topics for patient education. Almost all programmes edu-
cated patients on HF in general, detection of deterioration,
and advice and instruction on use of medication, diet, and
physical activity/exercise training. Smoking cessation was
addressed in three studies.25,26,31 Four programmes reported
education in coping with difficult emotions19,47,61,66 and one
study communicated with family and healthcare providers,
using relaxation and cognitive symptom management tech-
niques.60 Education on alcohol intake, sexual activity, and
necessity of vaccinations and capabilities of patients to
travel or work was described in one study.21 In one study,
individual problems, often related to comorbid conditions,
were given extra attention.67
Increased access to care
Increased accessibility to care was provided in 65 (93%)
of the 70 programmes, either by telephone support, home
visits, or telemonitoring. Some programmes used a stand-
ardized approach to increased accessibility to care by
planned visits to an outpatient clinic or planned telephone
support.14,23,24,3135,43,45,50,57,58,6163,66,6876 Others opened a
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helpline for patients in case of questions or prob-
lems.16,17,24,28,37,38,4044,51,61,63,63,7782 The opportunity to con-
tact healthcare providers for patients varied and the
healthcare provider is often available during office hours
or, in some programmes, 24 hours a day.
A different variety of systems for telemonitoring was
found, ranging from assessment of symptoms and/or vital
signs to data transmission and automatic alarms.
Discussion
This article provides an overview of studies evaluating home-
care interventions in the HF population during the past dec-
ades. The aim of the study was to describe the components of
the interventions and not focus on the outcomes and effec-
tives, since that has been addressed in previous reviews.8386
Although most studies included several components,
there was a large variety in the combinations of compo-
nents. The most common component in the articles was a
multidisciplinary team (99%). The least reported compo-
nent with 44% was optimized treatment according to guide-
lines. All articles described studies on interventions with
two components or more and 29% of the studies included
interventions with five components. Although we did not
aim to address the effectiveness of the separate components
or the effectiveness of the number of components, the vari-
ety in programmes indicate that standards of care to HF
management might be needed to further improve patient
care.2 It probably is not realistic to expect that components
can be separated in explaining effectiveness of disease
management programmes, since several components might
be related to each other. However, for teams that aim to
improve the quality of their existing programmes, the over-
view provided in this paper might be beneficial. The
recently presented WHICH? trial contains all five compo-
nents and is expected to provide important information
about optimal HF care in hospital or at home.87
Most programmes in this review reported working with
a multidisciplinary team. The content of the team varied
considerable per study and also the education of the profes-
sionals in the care for the patient with HF was not clearly
described or, if described, very heterogeneous ranging from
no additional HF training to, for example, a 2-month orien-
tation on HF. The Heart Failure Association of European
Society of Cardiology recently addressed the need for
appropriate education and training of healthcare profes-
sionals.2 Having a multidisciplinary composition of the
team did not always mean that the collaboration involved
different specialties, disciplines, and levels of HF care.
Collaboration between primary care and secondary care
were most often not clearly described. Within the studies
found in our review, there were only two studies in which
this collaboration between GPs and cardiologists was
mentioned explicitly related to the care of patients
with HF.
Jaarsma et al. 235

Table 2. Components of homecare studies.

Publication Design (n) Intervention MDT CP OT ES IAC Total

Adams and Quasi exp. Process- and outcome-focused standardized care + + + 3
Wilson (1995)30 (100)
Aguada RCT (104) Single home-based educational intervention + + + + + 5
et al.
(2010)31
Aiken et al. RCT (192) PhoenixCare intervention: case management and coordinated care + + + + + 5
(2006)32
Aimonino RCT (101) A physician-led hospital-at-home service + + + + 4
et al.
(2007)18
Antonicelli RCT (57) Home TM in elderly patients with congestive HF + + + + + 5
et al.
(2008)33
Balk et al. RCT (214) Teleguidance of chronic HF patients + + + + 4
(2008)67
Benatar RCT (216) Telemanagement and home nurse visits + + + + + 5
et al.
(2003)34
Blue et al. RCT (135) Home based nurse intervention + + + + 4
(2001)10
Bowles RCT (303) In-person home care, home care with telephone, and telemonitoring + + + + 4
et al.
(2009)22
Bowles RCT (218) Telehomecare + + + + + 5
et al. (2010)68
Brotons RCT (283) Home-based intervention + + + + + 5
et al. (2009)14
Burton Non- Care in the home for acute medical conditions + + + 3
et al. (1998)35 randomized
prosp.
(143)
Chaudhry RCT (1653) Telemonitoring + + + 3
et al. (2010)36
Chen et al. Non- Home-based intervention + + + + 4
(2010)78 randomized
prosp.(550)
Cleland RCT (426) Telemonitoring, nurse telephone support + + + + + 5
et al. (2005)37
Dansky RCT (108) Telehealth-based DM system + + + 3
et al. (2009)
Dansky RCT (284) Telehomecare + + + + 4
et al. (2008)69
Dar et al. RCT (182) Home TM on HF patients + + + + + 5
(2009)38
Del Sindaco RCT (173) Hybrid DM programme + + + + + 5
et al. (2007)15
Duffy et al. RCT (142) Caring-based intervention + + + + 4
(2005)39
Feldman RCT (530) Home health intervention + + + 3
et al. (2004)29
Feldman RCT (1242) Two information-based provider reminder interventions + + + 3
et al. (2005)40
Finkelstein RCT (53) Linking homebound patients with home healthcare nurses over + + + 3
et al. (2004)63 telephone system
Gary et al. RCT (74) Combined home-based exercise cognitive behavioural therapy + + + 3
(2010)66

(Continued)

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236 European Journal of Cardiovascular Nursing 12(3)

Table 2.Continued

Publication Design (n) Intervention MDT CP OT ES IAC Total

Giordano RCT (460) Home-based telemanagement program + + + + + 5
et al. (2009)41
Goldberg RCT (280) Technology-based, physician-directed daily weight and symptom + + + + 4
et al. (2003)42 monitoring
Harrison RCT (192) Hospital-to-home transition + + + + 4
et al. (2002)43
Heidenreich Non- Care is provided through multiple private physician offices + + + + 4
et al. (1999)44 randomized
prosp.
(155)
Ho et al. (2007)45 Non- Home- and clinic-based caring system + + + + 4
randomized
prosp.
(247)
Holland RCT (293) Effectiveness of visits from community pharmacists: HeartMed + + + 4
et al. (2007)24
Hughes RCT (1966) Team-managed home-based primary care + + 2
et al. (2000)81
Jaarsma RCT (179) Education and support by a nurse + + + + 4
et al. (1999)50
Jerant et al. RCT (27) Telecare + + + + + 5
(2001)46
Jerant et al. RCT (415) Intervention to enhance patient self-efficacy + + + 3
(2008)61
Johnston Quasi exp. Remote video technology + + + + 4
et al. (2000)62 (212)
Konstam RCT (188) SPAN-CHF intervention, with and without automatic home monitoring + + 2
et al. (2011)70
Kornowski Non- Intensive home-care surveillance + + + 3
et al. (1995)79 randomized
prosp. (42)
Kwok et al. RCT (105) Community nurse-supported hospital discharge programme + + + + 4
(2008)57
LaFramboise Non- The Health Buddy + + + 3
et al. (2009)76 randomized
prosp. (13)
Leff et al. RCT (563) Acute hospital-level care in a patients home in a hospital at home + + + 3
(2005)71
Mader et al. Non- Hospital at Home model + + + 3
(2008)72 randomized
prosp.
(225)
Mendoza RCT (71) Hospital at Home model + + 2
et al. (2009)75
Mortara RCT (407) Home telemonitoring: HHH study + + + + + 5
et al. (2004)80
Myers et al. RCT (166) Home-based monitoring on the care + + + + 4
(2006)52
Naylor et al. RCT (239) Transitional care intervention APN + + + + + 5
(2004)19
Noel et al. RCT (104) Health facilitys electronic medical record system + + + + 4
(2004)48
Peters-Klimm RCT (199) HF case management + + + + 4
et al. (2010)16

(Continued)

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Jaarsma et al. 237

Table 2.Continued

Publication Design (n) Intervention MDT CP OT ES IAC Total

Piette et al. Non- Automated assessment and behaviour change calls to patients, + + + 3
(2008)82 randomized feedback via Internet
prosp.
(173)
Piotrowicz et al. RCT New Home TeleCardiac Rehab programme + + + + 4
(2010)17 (77,75)
Rich et al. RCT (282) Multidisciplinary care + + + + + 5
(1995)55
Robinson et al. RCT Telehomecare + + + 3
(2004)49 (341, 85)
Rondinini et al. Non- Domiciliary-based nurse-led strategy + + + + 4
(2008)65 randomized
prosp. (61)
Schofield et al. Non- HF home-telehealth program + + + + + 5
(2005)56 randomized
prosp. (92)
Scott et al. RCT (88) Mutual goal setting & supportive-educative nursing interventions + + + + 4
(2004)64
Soran et al. RCT (315) Computer-based home DM program + + + + 4
(2008)26
Stewart et al. RCT (97) Home-based intervention + + + + 4
(1998)59 and
Pearson et al.
(2006)23
Stewart et al. RCT (200) HF-specific, multidisciplinary, home-based intervention + + + + + 5
(1999)20
Thompson et al. RCT (106) Hybrid program (clinic plus home-based intervention) + + + + 4
(2005)60
Triller et al. RCT (154) Visiting nurse association services + + + + 4
(2007)25
Vavouranakis Non- Home-based intervention + + + + 4
et al. (2003)28 randomized
prosp. (33)
Wakefield et al. RCT (148) Telehealth facilitated post discharge support + + + + 4
(2008)77
Weinberger RCT (1396) Increase access to primary care + + + + 4
et al. (1996)51
Weintraub et al. RCT (188) Automated health monitoring technology + + + + + 5
(2010)58
West et al. Non- MULTIFIT system + + + + + 5
(1997)54 randomized
prosp. (51)
Whitten and RCT (161) Home telehealth for patients + + 2
Mickus (2007)73
Wierzchowiecki RCT (160) Multidisciplinary care for HF patients + + + + + 5
et al. (2006)21
Wongpiriyayotha RCT (93) Home-based care program + + 2
et al. (2008)27
Woodend et al. RCT (121) Home telemonitoring + + + 3
(2008)74
Wright et al. RCT (197) HF diary and a schedule of daily self-weighing + + + + + 5
(2003)55
Total 70 69 47 31 61 65
MDT, multidisciplinary team; CP, care plan; OT, optimized treatment; ES, educational strategies; IAC, increased access to care, APN, advanced
practice nurse; DM, disease management; HF, heart failure; Prosp., prospective research; Quasi exp., Quasi experimental: RCT, randomized clinical
trial; TM, telemonitoring.

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238 European Journal of Cardiovascular Nursing 12(3)
The role of primary care is not always clear, but in many
countries primary practice is the most frequent point of con-
sultation for patients with deterioration of signs and symp-
toms of HF.2,12 Patients with HF also may consult other
healthcare workers such as cardiologist and/or HF nurses.12
To ensure the continuity and quality of care, it seems impor-
tant that there is a close collaboration between different dis-
ciplines and between primary care and hospital care. In
majority of studies, the cardiologist supervised the home
care of patients with HF. The GP was only mentioned in five
articles as being the supervisor of care. This reflects the cur-
rent state of the art in disease management in HF, namely
that there is a lack of continuity of care. The majority of HF
disease management programmes are primarily hospital
based with care delivered at outpatient clinics, occasionally
with outreach to patients homes by HF nurses.87
An important tool to ensure continuity of care is the care
plan or clinical pathway. Within this review, 47 (67%) out of
the 70 articles reported the use of care plans. Most of these
care plans are designed within the hospital environment and
implemented in primary care. Care plans are an important
part of the continuity and coordination of care of patients
with HF.9 A care plan consist of the medical history of the
patient, responsibility of health professionals, planned and
reached patients goals, patients wellbeing, and the treat-
ment plan. Care plans or clinical pathways consisted mainly
of patient goals, patients wellbeing, and treatment plan and
only seldomly the responsibility of health professionals.
Despite the ESC recommendations of including optimal
medical treatment in a HF management programme, only
23 (33%) out of the 70 intervention studies described medi-
cation titration as part of the intervention. Medication titra-
tion was often performed by the cardiologist or HF nurse in
the hospital and in five studies the GP was responsible for
adjustment of medication. This might reflect both the age
of some papers and also difference in practice, education,
and legal aspects in some countries. However, an increas-
ing role for medication uptitration in the patients home
might be possible using new telemonitoring approaches.8991
An important component of optimal care for patients with
HF is education and counselling of patients and families /car-
egivers. Education was a component in almost all programmes
and topics for education mostly entailed: HF in general, detec-
tion of deterioration,and advice and instruction on use of med-
ication, diet, and physical activity/exercise training. Only four
studies specifically addressing coping as a topic of education.
To improve this adherence to treatment, social relations
and a sufficient social network have proven to be very
important.1,2 Although the guidelines recommend that fam-
ily members should be invited to participate in education
programmes and decisions regarding treatment and first
studies indicate the importance of including family support,
only seven (10%) out of the 70 articles reported the families
and caregivers being involved in education.92
This study gives first insight in components included in
homecare programmes but did not give information about
Downloaded from cnu.sagepub.com by guest on December 23, 2013
effectiveness. This should be addressed in future reviews to
help the reader understand which components should be
further developed.
From this review, it is concluded that there are several
studies that focus on aspects of optimal HF care at home,
with a variety in number of components. Comparing the
results to current standards, aspects such as collaboration
between primary care and hospital care, titration of medica-
tion, and patient education can be improved.
Funding
This study was supported by the EU Seventh Framework
(Homecare 222954).
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