Self-Care Abilities of Patients with Heart Failure
Barbara J. Riegel, DNSc, RN, CS, FAAN

In a series of three funded clinical trials, Dr. Barbara Riegel and her research team have tested different disease management approaches to improving self-care and outcomes in elders with heart failure. In the first study, a multidisciplinary approach was used to bridge hospital and home for persons hospitalized with heart failure. Hospitalized patients had great difficulty learning to care for themselves during the abbreviated hospitalization periods currently provided. Therefore, an intervention designed for patients after they are discharged from the hospital was tested. In the second study, telephone case management began within a few days after hospital discharge and continued for six months. Patients receiving that intervention had an easier time learning self-care. Improved rates of rehospitalization and cost were evident in the patients randomized to receive the intervention.

Dr. Barbara Riegel

In the third study, patients with heart failure were taught to mentor other patients with heart failure. Although this intervention has been found to be acceptable and effective in other patient populations, it was poorly received by the patients in this study and ineffective in improving self-care or in decreasing acute care resource use. Further research is needed to understand why peer mentoring was less successful in persons with heart failure than in other patient populations.
During the course of these studies we developed a mid-range theory of self-care which was used to develop a paper-and-pencil instrument, the Self-Care of Heart Failure (SCHF) Index. The SCHF Index is a valid and reliable measure of self-care defined as a naturalistic decision making process involving the choice of behaviors that maintain physiologic stability (self-care maintenance) and the response to symptoms when they occur (self-care management). Further refinement of the SCHF Index is on-going.

To learn more about Dr. Riegel's research, please contact her at briegel@nursing.upenn.edu.

Effect of a Standardized Nurse Case Management Telephone Intervention On Resource Use in Chronic Heart Failure Patients
Barbara Riegel, DNSc, RN, CS, FAAN, Beverly Carlson, MS, RN, CCRN, CS, Zoe Kopp, RN, MPH, Barbara LePetri, MD, FACC, Allan Unger, PhD and Dale Glaser, PhD

Background: Case management is believed to promote continuity of care and decrease hospitalization rates, although few controlled trials have tested this approach. We assessed the effectiveness of a standardized telephonic case management intervention (Pfizer, Inc.’s At Home with Heart Failure™) in decreasing resource use in chronic heart failure patients.
Methods: A randomized controlled clinical trial was used to assess the effect of telephonic case management on resource use. Patients were identified at hospitalization and assigned to receive six months of intervention (n=130) or usual care (n=228) based on the group to which their physician was randomized. Hospitalization rates, readmission rates, hospital days, days to first rehospitalization, multiple readmissions, emergency department visits, in-patient costs, out-patient resource use, and patient satisfaction were measured at 3- and 6-months.
Results: The heart failure hospitalization rate was 46% lower in the intervention group at 3-months (p=0.03) and 48% lower (p=0.005) at 6-months. Heart failure hospital days and multiple readmissions were significantly lower in the intervention group at 6 months. In-patient heart failure costs were 45.5% (p=0.04) lower at 6-months. A cost savings was realized even after intervention costs were deduced. There was no evidence of cost-shifting to the out-patient setting. Patient satisfaction with care was higher in the intervention group.
Conclusions: The reduction in hospitalizations, costs, and other resource use achieved using standardized telephonic case management in the early months after a heart failure admission is greater than that usually achieved with pharmaceutical therapy and comparable to other disease management approaches.

From: Archives of Internal Medicine, 2002, 162(6), 705-712.
Key Words: heart failure, case management, telephone, cost, patient education

Facilitators and Barriers to Heart Failure Self-Care
Barbara Riegel, DNSc, RN, CS, FAAN and Beverly Carlson, MS, RN, CCRN, CS

Self-care of heart failure (HF) is difficult to master, but the reasons why remain unclear. The purpose of this study was to explore how HF influences patients’ lives, assess how they perform self-care, and determine how their life situation facilitates or impedes HF self-care. Qualitative data were obtained from 26 individuals with chronic HF. Data were gathered using structured interviews and analyzed using content analysis. Physical limitations, debilitating symptoms, difficulties coping with treatment, lack of knowledge, distressed emotions, multiple comorbidities, and personal struggles were common. Self-care involved the recognition of symptoms, but atypical symptoms such as faintness were rarely attributed to HF. Patients discussed their successes and failures in following dietary, exercise, and medication recommendations. Some adaptation strategies were practical and some involved internal resources. Many patients accepted support from others, but some withdrew. With the number of barriers these patients face, it is not surprising that self-care of HF is typically poor and that readmission rates continue to be high. Recommendations are provided for a stepped approach to patient education and counseling that uses these findings in practice.
From: Patient Education and Counseling, 2002 46(4), 287-295.

Key Words: heart failure, self-care, compliance, social support, patient teaching, Precede-Proceed model

Self-Care Abilities of Patients with Heart Failure
Beverly Carlson, MS, RN, CCRN, CS and Barbara Riegel, DNSc, RN, CS, FAAN

Background: Self-care of heart failure is difficult for patients because early symptoms are subtle and the treatment regimen is complex. The primary purpose of this study was to describe heart failure self-care abilities and the difficulties that patients experience in achieving success in self-care. A secondary purpose was to compare self-care abilities in patients experienced with heart failure and those newly diagnosed.
Methods: A descriptive, cross-sectional, comparative survey was conducted. Surveys were used to assess demographic and clinical factors that may interfere with self-care and life-style changes made to accommodate the diagnosis. Symptoms experienced and self-care responses to symptoms were assessed using the Self-Management of Heart Failure questionnaire.
Results: The 139 subjects were primarily elderly, male, retired, unmarried, and earning less than $20,000 annually. Hearing and eyesight were impaired and most were functionally compromised. Most of the sample had experienced multiple heart failure symptoms over the past year. Yet, their knowledge of the importance of signs and symptoms was poor and many misperceptions were evident. Recognition of changes in signs and symptoms was difficult for most, but easier for experienced patients. Those experienced with heart failure were somewhat more likely to use appropriate self-care remedies than the newly diagnosed patients. Few were comfortable evaluating the effectiveness of their self-care actions and most had low self-confidence in their ability to perform self-care.
Conclusions: With the level of self-care ability low and the number of difficulties these patients face, it is not surprising that readmission rates continue to be high. Specific recommendations for teaching and the delivery of care are provided.
Key words: heart failure, self-care, compliance, self-efficacy.

From: Heart and Lung 2001: 30 (5):351-9.

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