Benefits of Comprehensive Inpatient Education and Discharge Planning Combined With Outpatient Support in Elderly Patients With Congestive Heart Failure

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Abstract
Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce read‐mission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse‐driven home health care program. The comprehensive intervention resulted in a marked reduction in 6‐month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow‐up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.
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