Congestive heart failure is the most common reason for hospitalization of the elderly. Breaks in patient compliance with medication regimens frequently exacerbate the disease and lead to more hospital visits. A major principle of the comprehensive approach outlined above is to prevent these occurrences through patient education and frequent monitoring. Nurses, social workers, dietitians, and members of other professions are often involved in these activities, although the 3 elements critical to the success of outpatient programs center on the physician, physician extender, and home health care provider ().
Critical Staff in the Heart Failure Care Program
The program should include intensive teaching, distribution of informational materials on congestive heart disease, recommendations about diet, an emphasis on simplifying the medical regimen, implementation of home care services, and regular telephone contacts. In a randomized trial of high-risk patients aged 70 or older, readmissions were reduced by 56% in those who received these services after being hospitalized for congestive heart failure when compared with the control group. This resulted in a saving of $460 per patient over a 90-day period (4). Quality of life scores also improved for patients in the treated group. A separate analysis of a subset of the patients in the same trial found that the comprehensive strategy significantly improved compliance with the medication regimen. This may be the reason patients in these programs have better health outcomes (5). In another study, candidates for heart transplantation were referred to a program that focused on increased use of angiotensin converting enzyme (ACE) inhibitors, a flexible diuretic regimen, diet, and exercise counseling. Hospital admissions were reduced 85% in the 6 months after referral, compared with the prior 6 months. The patients' functional status improved as well. The estimated saving from hospital costs during the post-referral period, after subtracting the initial costs for evaluation, was $ 9,800 per patient (6). These 2 studies are similar with regard to the comprehensive and concerted nature of the outpatient and home care provided, but differ in the populations studied. The first investigation by Rich et al (4) examined elderly subjects with a mix of diastolic and systolic heart failure. The second study by Fonarow and colleagues (6) primarily investigated a younger population of patients with systolic dysfunction and little major comorbidity. Yet the results of a focused approach revealed the same findings. Optimal and continued outpatient care decreased hospitalizations, reduced inpatient stay, and improved quality of life, while decreasing overall care costs. Unfortunately, these studies can be criticized because they occurred in specialized centers with a broad-based referral network and do not primarily involve heart failure patients that are recycled from within a defined population.