475137

Health Care Management & PracticeDelaney et al.

2013
HHC25510.1177/1084822312475137Home

Original Article
Home Health Care Management & Practice

A Randomized Trial of
25(5) 187195
2013 SAGE Publications
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DOI: 10.1177/1084822312475137
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Education in Heart Failure
Patients Following Home
Care Discharge

Colleen Delaney, PhD, RN, AHN-BC1, Beka Apostolidis, RN, MS2, Susan Bartos, RN, BS1
Heather Morrison, RN, MS1, Liane Smith, RN, BSN2, and Richard Fortinsky, PhD3

Abstract
Patients with heart failure (HF) who have been discharged from a home care agency are a particularly vulnerable group at
risk for poor outcomes and high rehositalization rates. The primary aim of this experimental study was to determine the
efficacy of a telemonitoring and self-care education intervention in reducing hospitalization and improving quality of life and
patients knowledge of HF after home care discharge. Ninety-three participants completed the study. The primary outcome
of 90-day posthome care discharge hospitalization was significantly reduced in the intervention group compared to controls
(9 vs. 18, p - .046). HF knowledge (p = .013) and QOL (p = .004) were significantly increased in intervention group patients
in comparison to control group patients at the study endpoint.

Keywords
heart failure, home care, telemonitoring, self-care, cardiovascular, research

Heart failure (HF) is a chronic, progressive condition that is
characterized by poor physiological and psychological out-
comes. An estimated 5.7 million Americans are currently
affected by HF,1 and this figure is expected to double over
the next 25 years, primarily because of the aging of the popu-
lation and decreased mortality from other cardiovascular
conditions.2 HF is widespread among the aging population.
It is most common diagnosis among Medicare beneficiaries,3
and HF patients are one of the most common patient groups
in home health care.4 Individuals with HF suffer incapacitat-
ing physical symptoms, emotional distress, impaired quality
of life, repeated hospitalizations, and premature death.5-8
Patients with HF who have been recently discharged from
a home care agency are a particularly vulnerable group at
risk for poor outcomes and high rehospitalization rates.
These patients tend to be older, more frail, and have greater
health care needs than the general HF population9 and thus in
most need of ongoing patient-centered care.
It is well known that HF patients are often caught in a
revolving door from hospital to home care, discharged back in
the community, and then repeating the cycle.10 Most studies
have originated in hospital settings seeking to intervene at the
juncture when patients are discharged; a few studies have been
conducted at the juncture during home care admission seeking
to improve HF outcomes, and only one study was found with
home health care patients at discharge.11 Further studies are
needed to determine whether continued monitoring of HF
patients following formal home care services is effective in
improving HF outcomes. The purpose of this study was to
examine the influence of an intervention combining telemoni-
toring (TM) and self-care education on the frequency hospital-
ization in adults with HF following home care. Secondary
outcomes included quality of life (QOL) and HF knowledge.
Background
Home care agencies are major providers of health care ser-
vices to adults, primarily older adults, with HF. The National
Home Care Survey shows that primary diagnosis of HF con-
sistently ranks in the top three admitting diagnoses in home
care4 HF patients who are referred to a home care agency
represent a cohort of patients at high risk for poor outcomes.
1
University of Connecticut School of Nursing, Storrs, CT, USA
2
VNA Healthcare, Inc, Hartford, CT, USA
3
University of Connecticut Health Center, Farmington, CT, USA
Corresponding Author:
Colleen Delaney, PhD, RN, AHN-BC, University of Connecticut School of
Nursing, 231 Glenbrook Rd, Storrs, CT 06269, USA.
Email: Colleen.Delaney@uconn.edu

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188
Home care patients experience higher hospitalizations
rates than the general population. In a recent study of
Medicare beneficiaries with a primary diagnosis of HF rep-
resenting the general HF population, 30-, 60-, and 90-day
rehospitalizations rates were examined. Authors report that
these rates were 28%, 34%, and 37% respectively.12 The
Agency for Health Quality research reports that the 30-day
rehospitalization rate for HF is 25.13%.13 In contrast, HF
patients referred to home care agencies have 30-day hospi-
talization rates near 30%.14 These findings indicate that
home care patients are a vulnerable group at high risk for
rehospitalization.
As part of the continuum of care, home health services are
an important component of managing HF. The standard epi-
sode of care is 60 days or less, and many HF patients expe-
rience exacerbations of their illness, requiring hospitalization
soon after they are discharged from home care.11
Consequently, there is a critical need for evidence-based and
theoretically grounded best practices in HF care to improve
outcomes for this high-risk population in the home care set-
ting and to facilitate patients transition to independent self-
care following home care discharge. The use of telemonitoring
and self-care education as a HF management strategy during
and beyond formal home care services may offer a solution
to the revolving door of hospital admissions providing
enhanced quality of care for patients and families.
Best Practices in Community-Based
HF Management
Telemonitoring
TM and self-care education has been identified as best prac-
tice strategies in community-based HF management. TM is
becoming increasing popular in home care settings and takes
on various formsfor example, telephone-based symptom
monitoring, automated monitoring of signs and symptoms,
and biometric monitoring (blood pressure, heart rate, weight,
oxygen saturation) via a monitor placed in a patients home.
To date, TM studies have provided inconclusive results.
Several studies have demonstrated improved clinical out-
comes with the use of TM.15-19 However, other studies 19-21
failed to find statistically significant differences between TM
patients and traditional care patients for hospitalizations.
A recent randomized control trial followed patients with a
primary diagnosis of HF during formal home care and 180
days following home care discharge.11 The intervention
group patients received a Health Buddy telehealth system
that was programmed to ask collect clinical data and ask
questions related to HF self-management daily. Results
found that continued use of the Health Buddy for 180 days
had a significant effect on the number of inpatient hospital
admissions. Among the 64 patients in the telehealth group,
none (0%) reported any inpatient admission, compared to 13
(28.3%) patients in the control group (p < .001).
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Home Health Care Management & Practice 25(5)
A recent Cochrane review of various types of TM con-
cluded that telemonitoring of patients with HF reduced the
rate of death by 44% and the rate of hospitalizations by 21%.22
But the review noted that the methodological quality of these
studies was variable, that many studies were small, and that
further research was needed. Though TM studies demonstrate
mixed results, the increasing use of this strategy in commu-
nity-based HF care is a compelling reason to continue research
on the effectiveness of this technology on HF outcomes.
Furthermore, research demonstrates that TM enhances self-
care knowledge by assisting patients in establishing a self-care
routine and reinforcing symptoms to be monitored daily.23
Self-Care Education
The American College of Cardiology and American Heart
Association (ACC/AHA) joint guidelines24 identify educa-
tion of HF patients and their families as critical. They note
that failure of HF patients to understand the importance of
compliance with health care providers instructions exacer-
bates HF and results in hospitalization. Numerous studies
have used nurse-led self-care educational interventions with
HF patients.25-28 These studies provide evidence of the ben-
efits of nurse-led self-care education care in reducing
unplanned admissions, health care costs, and improving
QOL. In a recent analysis of self-care educational interven-
tions, the authors provide evidence that self-care education
reduces reghospitalization rates29 However, the analysis
indicated that the influence of self-care education on QOL is
unclear. QOL was improved in 9 out of 17 studies as a result
of self-care interventions, and findings of all repeated-mea-
sures studies indicated improvements in QOL.29
In summary a review of the literature reveals gaps in the
literature related to HF research after formal home care ser-
vices. In addition, studies show inconclusive results with
TM. Most recently, there has been debate regarding TM and
these mixed findings. Self-care is at the center of this debate.
It is believed that TM is most effective when it enhances
self-care skills, uses daily, real-time monitoring of physio-
logical data, and direct patient feedback and education to
achieve positive results. Moreover, studies on the influence
of self-care on QOL are inconsistent. This study helps to fill
gaps in the literature by testing an intervention that combines
TM and self-care education with HF patients after discharge
from home care.
Conceptual Framework
The intervention was based on the conceptual model of Self-
Care in HF.30 Self-care is the process whereby individuals and
caregivers perform daily activities to maintain or restore
health and well-being, prevent illness, and manage chronic
illness.8 Within this framework, self-care management and
maintenance are conceptualized as key patient behaviors.
Self-care management involves recognizing a change (such as
Delaney et al
increasing edema), evaluating the change, deciding to take
action, implementing a treatment strategy (e.g., take an extra
diuretic dose), and evaluating the response to treatment.30
Self-care maintenance refers to healthy lifestyle choices and
treatment adherence (e.g., monitoring symptoms and weight,
following recommended diet, and taking medications).30
Educational protocols used in this study were aimed at
increasing patients self-care knowledge and skills.
Method
Research Design
A randomized controlled trial (RCT) was used to test the
hypothesis that patients in the experimental group would
show fewer hospital readmissions, improved QOL, and
increased HF knowledge at 90 days than would patients in
the control group
Research Aims and Hypotheses
Specific Aim No. 1: Determine the effectiveness of the
telemomitoring and self-care education interven-
tion in reducing hospital readmission rates.
Hypothesis 1: Patients receiving the telemomitoring
and self-care education intervention will demon-
strate a decrease in hospital readmission rates com-
pared to the control group.
Specific Aim No. 2: Determine the effectiveness of the
telemomitoring and self-care education interven-
tion in improving self-reported quality of life.
Hypothesis 2: Patients receiving the telemomitoring
and self-care education intervention will report
improved self-reported quality of life compared to
the control group.
Specific Aim No. 3: Determine the effectiveness of the
telemonitoring and self-care education intervention
in improving patients knowledge of HF.
Hypothesis 3: Patients receiving the telemomitoring
and self-care education intervention will demon-
strate improved HF knowledge compared to the
control group.
Setting and Sample
The study was conducted in a large multibranch home care
agency in Connecticut. The study was reviewed and
approved by the Internal Review Board at the university.
Potential participants who were referred to the agency fol-
lowing a HF hospitalization were identified by the cardiac
program manager of the home care agency. Prior to recruit-
ment in this study, all patients received 4 to 8 weeks of home
care services from the home care agency participating in the
study The agency had introduced TM about 5 years earlier
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189
with the objective of improving HF care. Telemonitoring is
now offered to all patients with a primary diagnosis of HF as
an addition to traditional home care and had become so com-
mon that it is considered usual care. All study patients had
TM during formal home care services and received skilled
nursing care. Nursing care was based on evidence-based
clinical guidelines for management of HF. The guidelines
identify assessment parameters, educational topics, and
expected outcomes for each visit.
Eligibility Criteria
HF patients recently discharged from home care were eligi-
ble to participate in this study if they were (a) English-
speaking adults age 21 years or older, (b) primary diagnosis
of a HF, (c) hospitalized for HF excacerbation prior to home
care admission, (d) living at home, and (e) had access to in-
home phone line.
Telemonitoring and Self-Care Education
Intervention
Participants in the intervention group continued use of a tele-
monitor that was installed in the patients home for an addi-
tional 90 days posthome care discharge. The HomMed
Health Monitor is an FDA Class II Medical Device. The
telemonitor records weight, blood pressure, heart rate, and
oxygen saturation. The monitor is programmed to ask patients
to respond to five questions such as are you short of breath?
and have you had any chest pain? Information is then trans-
mitted over phone lines to a central server at the home care
agency. The TM Program manager receives this information
daily and reviews data each morning and contacts the patient
if indicated. Patients are informed that this is not a 24-hr or
emergency service and are instructed to go to the ER or con-
tact their MD with symptoms of HF or chest pain.
A HF self-care booklet developed specifically for this
study that incorporated ACC/AHA guidelines,24 current
nursing guidelines31 and reprinted American Association of
Heart Failure Nurses materials with permission was given to
intervention patients.32 Content included information related
to HF etiology, symptoms to monitor, diet, fluids and weight,
medications, exercise, and stress management. The study
nurses reviewed all materials with patients during a 1-hr ses-
sion following enrollment. The purpose of this education
session was to reinforce and expand on previous HF educa-
tion during home care.
Attention Control Condition
Patients were provided with a Medication Tracker diary to
record their medications, any missed doses, and/or symp-
toms each day for 90 days. Control group patients received
usual care discharge instructions. Their TM was removed on
home care discharge.
190
Variables and Measures
Patient outcome data were collected at home care discharge
and 90 days posthome care discharge. Hospital readmis-
sion was recorded from patient self-report (validated with
agency report). Hospital readmission data was assessed at 2
time points, 30 days posthome care discharge and 90 days
posthome care discharge. All cause 90-day hospitalization
following formal home care services was selected as the
primary outcome to allow us to fully evaluate the effect of
the 3-month TM and self-care education intervention.
Secondary outcomes were 30-day hospitalization post
home care discharge, QOL, and HF knowledge.
QOL was evaluated with The Minnesota Living with
Heart Failure (MLHF) questionnaire,33 a 21-item, self-
administered questionnaire designed to measure the effects
of heart failure and treatments for heart failure on an indi-
viduals quality of life. To measure the effects of symptoms,
functional limitations, and psychological distress on an indi-
viduals QOL, the MLHF questionnaire asks persons to indi-
cate (using a 6-point, 0-5 self-report scale) how each of the
21 facets preventing them from living as desired. The MLHF
has demonstrated reliability and validity in several stud-
ies.34-35 Most recently, the internal reliability coefficient was
estimated at 0.86. Other research findings provide evidence
of the concurrent and construct validity of the scale.36
HF knowledge was measured with The Dutch HF knowl-
edge scale,37 a 15-item, self-administered questionnaire that
covers HF knowledge in general, knowledge on HF treat-
ment (including diet and fluid restriction) and HF symptoms
and symptom recognition. Content validity was estimated by
a panel of 10 HF experts; all items achieved 100% valida-
tion. Factor analysis was completed using principal compo-
nents extraction with oblimin rotation supporting a single
factor structure. The scale is used as a total scale score and
reliability analysis was performed only for the total scale.
Psychometric testing of the instrument with 902 HF patients
provided evidence of the reliability of the instrument. The
scale was able to differentiate between HF patients with high
and low level of HF knowledge. Cronbachs alpha of the
scale in this sample was .62.37
Procedure
After receiving study approval from the university IRB,
participants were recruited through the home care agency
prior to discharge. The adults who expressed interest in par-
ticipating were told they would be contacted by a member of
the research team on home care discharge. A member of the
research team then met with patients who expressed interest
to explain the purpose of the study, procedures, and time
commitment involved; answer any questions; and invite
eligible participants to participate in the study.
Prior to being randomized, patients signed a consent
form, filled out a baseline demographic questionnaire, and
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Home Health Care Management & Practice 25(5)
completed the MLHF and Dutch HF Knowledge question-
naires. Randomization was carried out in advance by a stat-
istician at the university. Participants were randomized at a
2:2 ratio to the intervention and control groups. The study
nurses were provided with a box of sealed opaque envelopes
commonly used in RCTs38 that they opened after each patient
had completed the baseline questionnaires. Patients then
were informed of their randomization assignment.
Statistical Analysis
The sample size for analysis was 100 (50 in the intervention
group and 50 in the control group), which provided 80%
power to detect a moderate reduction in the rate of hospital
readmission across 90 days of follow-up. This sample size
allowed for a 10% attrition rate typically found in longitudi-
nal studies with HF patients.39 Additionally, the sample size
provided 80% power to detect a difference between the
intervention and control conditions in mean posttest-versus-
pretest changes on the Dutch Heart Failure Knowledge Scale
and 93% power to detect clinically significant difference in
MLHF scores of 6-points.
Demographic and clinical variables were summarized as
mean and standard deviation for continuous variables and as
count and percentage for categorical variables. Before
hypothesis testing descriptive statistics were computed for
all study variables using the Statistical Package for the
Social Sciences for Windows (Version 19.0; SPSS Inc.,
Chicago, IL) and examined for random and systematic miss-
ing data. No systematic missing data were found; random
missing data were minimal and handled using median
substitution.
The primary outcome of 90-day hospitalization post
home care discharge and secondary outcome 30-day hospi-
talization posthome care discharge were evaluated using
the pearson chi-square test. Other secondary outcomes
(QOL, HF Knowledge) were evaluated using repeated-mea-
sures analysis of variance (ANOVA) with intervention group
and time as predictors of QOL and HF knowledge.
Results
Flow of Participants
Recruitment began in June 2011 and ended in August 2012.
The intervention was conducted for 3 months for each par-
ticipant, and data collection ended in September 2012. As
can be seen in Figure 1, a total of 278 patients were assessed
for eligibility, 92 were excluded based on the study criteria.
An additional 86 declined to participate. A total of 100 HF
patients were enrolled in the study on discharge from home
care. Seven patients dropped out of the study over the 90
days resulting in a 7% attrition rate (I patient died, 3 refused
TM installation, 3 were unable to be contacted for follow-
up data)
Delaney et al
Assessed for eligibility (n=278)
Enrollment
Randomized (n=100)
Allocation
Allocated to intervention (n=50)
Received allocated intervention (n=47)
Did not receive allocated intervention
(refused TM install (n=3)
Follow-Up
-up (unable to locate (n=1)
Lost to follow-up (unable to locate (n=1)
Analysis
Analysed (n=46)
Figure 1. Flow of participants through the TM and self-care intervention study.
Sample Description
Ninety-three patients completed the study (46 in the inter-
vention group and 47 in the control group). The demo-
graphic characteristics of the two groups are shown in
Table 1. The typical participant in the TM and Self-care
education group was a White married woman 78 years of
age with a high school education who was retired. The typi-
cal participant in the attention control group was a married
woman approximately 82 years of age, with a high school
degree and retired. The numbers of comorbidities and medi-
cations were similar between groups
Study patients had between 2 and 4 comorbid diagnoses,
with the most common diagnoses being hypertension (52%
intervention, (46% control), diabetes (36% intervention,
22% control), and arthritis (28% intervention, 25% control).
The number and type of HF medications were also similar
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191
Excluded (n=178)
Not meeting inclusion criteria (n=92)
Declined to participate (n=86)
Allocated to attention control (n=50)
Received attention control condition (n=50)
Lost to follow-up (unable to reach) (n=4)
Analysed (n=47)
across groups. All patients were on a combination of medica-
tions representative of current HF management guidelines.
The vast majority of study patients (95%) represented Class
III on the NYHA HF classification categories.
The principal difference between the groups was age and
living arrangements. Patients in the control group tended to be
slightly older than their intervention group counterparts (p =
.021) and more patients lived alone (p = .011). There were no
other statistically significant differences on other demographic
characteristics or baseline QOL and HF knowledge scores.
Primary Outcome 90-day PostHome Care
Discharge Hospitalization
For the primary outcome, 90-day all cause hospitalization
posthome care discharge, there was a significantly lower
readmission rate in the intervention group than in the control
192 Home Health Care Management & Practice 25(5)

Table 1. Demographic Characteristics of Study Participants.

Intervention Control

Demographic Frequency Percent Frequency Percent P value

Age 0.02
Below 49 1 2.2 2 4.3
50-59 3 6.5 0 0
60-69 7 15.2 1 2.2
70-79 13 28.3 7 15.2
80-89 16 34.8 26 56.5
90 or higher 6 13.0 10 21.7
Gender 0.82
Female 32 67.2 33 68.1
Male 14 32.5 14 31.9
Education 0.68
Elementary 8 17.4 9 19.5
High School 23 50 26 53.3 Figure 2. 90-day all cause posthome care discharge hospital
Associate degree 11 23.9 19.2 19.2 admissions.
Bachelor 3 6.5 2 4.3
Masters degree 1 2.2 1 2.1
Ethnicity 0.51
White 35 71.8 39 83.0 Secondary Outcomes
African American 9 19.6 6 12.8
Hispanic 2 4.3 2 4.3 30-day posthome care discharge hospitalization. There was
Asian 1 2.2 0 a trend toward decreased hospitalization in intervention group
Marital status 0.07
Single 6 12.0 5 10.6
patients at 30 days following home care discharge. However
Married 24 52.2 16 34.0 this was not statistically significant. A total of 11 study
Divorced 4 8.7 2 4.3 patients were readmitted to a hospital during the first month
Widow 12 26.1 24 51.1
following home care discharge (4 intervention, 7 control).
Living 0.01
arrangements No significant differences between the intervention and
Alone 10 21.7 21 44.7 control groups were observed in hospital readmission due to
With someone 36 78.3 26 55.3 HF. There were 2 patients in the intervention group and 4 in
else
Work 0.34 the control group hospitalized due to HF within 30 days of
Part-time 2 15.4 2 12.8 home care discharge.
Retired 38 82.6 45 87.2
Comorbid 0.91
diagnoses QOL
2 23 50.0 27 58.0
3 12 25.0 12 25.0 An examination of the means for the Group X Time interac-
4 11 25.0 8 16.0 tion revealed that QOL scores significantly changed from
NYHA 1.00
Class III 42 95 43 95
baseline at home care discharge to 90 days following home
Class IV 4 5 4 5 care discharge in the intervention group. Preintervention
MLHF scores for patients in the intervention group (mean =
45.5; SD = 18.3) were significantly lower following the
intervention (mean = 32.1; SD = 15.3, p = .004). In com-
parison, mean QOL scores in the control group remained
group (p < .046). During the first 90 days following home care similar to baseline scores. No change was observed in the
discharge, 9 patients (19%) in the intervention group and 18 before (mean = 42.9; SD = 16.2) and after MLHF scores for
patients (38%) in the control group were hospitalized. Since those in the control group (mean = 42.4; SD 16.7). ANOVA
there were significant differences in age and living arrange- was followed by linear regression analysis to test the inter-
ments between the two groups, we conducted logistic regres- vention effect controlling for age and living arrangements.
sion analysis to test the intervention effect controlling for This significant effect remained after controlling for age and
these variables. This significant effect remained after control- living arrangements (p = .008).
ling for age and living arrangements (p = .011). Figure 2 dis-
plays all cause 90-day posthome care hospitalization rates.
Further analyses were conducted to examine hospitaliza- HF Knowledge
tion rates by comparing HF-related admissions and all other Both groups increased their knowledge of HF over time. The
causes of readmissions. Of the 9 readmissions in the inter- increase in HF knowledge the intervention group was sig-
vention group, 3 were HF-related and 7 out of 18 admissions nificantly higher (p = .019) than that in the control group
in the control group were HF related. No significant differ- (increase in control group was statistically nonsignificant).
ences were seen between groups in HF-related admissions. Mean baseline HF knowledge scores were 11.7 (SD = 1.8) in

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Delaney et al
Table 2. Baseline and 90-Day Follow-Up Scores of Quality of Life and Heart Failure Knowledge Outcome Variables.
Baseline
Outcome variable Mean (SD)
Quality of life
Intervention group 41.57 (18.3)
Control group 42.94 (16.2)
HF knowledge
Intervention group 11.78 (1.8)
Control group 11.03 (2.4)
Note. Hierarchical linear regression analysis controlled for age and living arrangements
the intervention group and 11.0 (SD = 2.4) for control group
patients. The mean overall improvement in the HF knowl-
edge scores in the intervention group was 1.4 points,
F(1, 91) = 6.401, p =.013, compared to 0.5 points in the
control group which proved to be significant. This effect
also continued after controlling for age and living arrange-
ments (p = .017). Table 2 displays the pre- and postinterven-
tion scores for QOL and depression in the intervention and
control groups.
Other Outcomes
Telemonitoring outcomes of intervention patients were
assessed by recording the number of phone calls placed to
patients by TM nurses and abnormal findings on daily data.
Of the 46 patients in the intervention group, 15 patients were
contacted by the TM nurse. The most frequent reasons for
contacting patients in the intervention group were weight
gain, decreased blood pressure, and increased shortness of
breath. The vast majority of calls were managed on the
phone and no additional skilled nursing visits were required.
TM nurses instructed patients to contact their physician for
any finding over the established parameters, which resulted
in 4 patients having their medications adjusted. In addition,
the TM nurses called 911 for two patients who reported
severe dyspnea in response to the daily question related to
shortness of breath on the TM transmission. Those two
patients were subsequently hospitalized earlier than they
may have been had the TM nurse not intervened, possibly
preventing further HF decompensation.
Field notes were kept during the postintervention follow-
up interview at 90 days to assess patients experiences with the
intervention. Patients reported a high level of satisfaction with
the continued TM and self-care education session following
home care discharge. One patient stated The TM and the edu-
cation booklet helped me gain independence in caring for my
HF once the nurse stopped visiting and I was on my own.
Another patient stated, I was glad to be part of this program
and hope the agency continues to offer this service after
patients are discharged. I think many patients will benefit
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193
Hierarchical Linear
ANOVA Regression
90-Day Follow-up F value
Mean (SD) Significance Significance
32.10 (15.3) F = 8.66 = .278
42.42 (16.7) p = .004 p = .011
13.10 (2.2) F = 6.40 = .225
11.37 (1.9) p = .013 p = .039
Discussion
This RCT was designed to evaluate the effect of a TM and
self-care education intervention on hospital readmission,
QOL, and HF knowledge in HF patients following home
care. Results showed a significant decrease in all cause
hospitalization at 90 days following home care discharge in
the experimental group compared with the control group
and a trend toward decreased rehospitalization at 30-days
posthome care discharge. QOL and HF knowledge were
significantly increased in intervention group participants.
However, it should be noted that previous studies have
demonstrated mixed results with both TM and self-care
education on QOL.
Participants in study were predominately classified as
Class III on the NYHA classification scale. According to the
authors of the MLHF questionnaire, patients in this category
typically score in the 50s.33 In this sample, patients baseline
mean scores were in the 40s. A possible explanation for the
lower self-reported scores may be that most patients had
passed the acute phase of illness and perceived their health
as greatly improved compared to the recent past.
From a theoretical perspective, the present intervention
was based on the theory of HF self-care, focusing on self-
care maintenance (monitor symptoms daily) and manage-
ment (acting on changes in health status) and encouraging
confidence in living with HF. A small but significant increase
in HF knowledge was found in the experimental group com-
pared to the usual care group. This finding suggests that an
individualized self-care education session posthome care
discharge combined with daily TM may enhance HF self-
care knowledge and abilities and consequently decrease
rehospitalization and improve QOL.
A strength of this study was the focus on a previously
understudied population of HF patients posthome care dis-
charge. The patients in this study were willing to engage in a
TM and self-care intervention to manage their HF providing
evidence of the feasibility of this intervention.
The limitations of this study include its small sample size
and its predominately White participants. In addition, the
194
setting was limited to one multibranch agency, a specific
geographic location. These limitations reduce the generaliz-
ability of the study findings to diverse ethnic populations in
other areas of the country.
The findings of this study add to the growing body of lit-
erature that will inform and guide home care managers and
clinicians who are responsible for integrating TM and educa-
tion into HF management protocols. Promising findings
from this study suggest that home care agencies may benefit
from continuing TM and providing a brief self-care educa-
tion session post discharge. Furthermore, agencies not cur-
rently using TM or other types of telehealth may consider
adding this technology into chronic disease protocols such as
HF management. Future research based on a large multisite
randomized trial would help to determine the efficacy of this
intervention in improving health related outcomes for adults
with HF posthome care discharge.
Acknowledgments
The authors gratefully acknowledge Jefferson House and VNA
Healthcare for funding this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) declared the receipt of the following financial
support for the research, authorship, and/or publication of this
article: The PI, Dr. Delaney, received a small stipend ($3,000) for
managing the study. The study was funded by VNA HealthCare
and Jefferson House for $51,000. This majority of this funding
covered telemonitoring costs.
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