Heart failure patients present challenges

Comorbidities, patient attitudes make care difficult

Patients with heart failure may be among the most challenging for case managers who are coordinating their care. Patients with heart failure must take multiple medications, eat a low-salt diet to keep their condition under control, and monitor their condition constantly. And even if they do everything right, they are likely to find themselves back in the hospital or emergency department several times a year.

"Heart failure has substantial quality-of-life implications for patients. It has a higher mortality rate than most cancers, and it's difficult to get patients to manage their condition because they think it's an episodic event and not a chronic disease," says Jill Howie-Esquivel, PhD, RN, FNP, associate clinical professor at the University of California-San Francisco School of Nursing.

It's also an expensive disease. The American Heart Association estimates that heart failure will cost $26.9 billion in direct and indirect costs in 2006 for the 5 million people with the condition. The organization estimates that about 500,000 patients are diagnosed with the condition every year. Heart failure deaths have doubled since 1979 and average 250,000 a year.

"Congestive heart failure is one of the largest admitting diagnoses to acute care hospitals. It's a diagnosis with a high mortality rate, and patients with heart failure consume a lot of health care resources, says Pam Hagley, RN, BSN, MSHA, ACN, director of clinical resources at New Hanover Regional Medical Center in Wilmington, NC.

A telephonic case management program for heart failure patients who have been discharged from the hospital has cut readmissions and reduced length of stay, Hagley says.

Many heart failure patients also suffer from depression, a condition that makes it difficult for them to manage their condition, points out Rick Precord, MSW, director of clinical care management at Health Alliance Plan (HAP) based in Detroit.

HAP's case managers screen all their heart failure patients for depression and refer those who screen positive to the health plan's behavioral health specialists.

When Howie-Esquivel conducted a study of heart failure patients to determine what factors can be used to predict which patients would be readmitted to the hospital, she found that an astonishing 50% of the 72 patients she followed were readmitted within 90 days.

The average age of the patients was 61, and 50% were anemic upon admission and scored 3.25 on the New York Heart Association Classification for Congestive Heart Failure, a four-point scale for classifying heart failure patients.

She looked at clinical factors and activities of daily living, such as how far the patient could walk in six minutes. Her studies showed that women and people who are not white are more likely to be hospitalized.

"I was surprised to find that gender and ethnicity were stronger predictors of outcomes than hard clinical data," she says.

One factor may be that the women patients were more frail than the men. They couldn't walk as far, an indicator that they might have problems taking care of themselves at home, Howie-Esquivel says.

Another factor could be that many heart failure patients do not understand their disease. They don't understand that they have a chronic illness that won't ever go away.

"Patients don't understand that when they leave the hospital, they still have heart failure. They think it's like pneumonia. You have it and you're treated and then you're cured," says Renee Slater, RN, a case manager with New Hanover Medical Center's telephonic heart failure case management program.

Case managers should work to help heart failure patients understand that they must think about their disease every day, monitoring their sodium intake at every meal, weighing themselves every day, and calling their doctor if they gain weight, Howie-Esquivel says.

"Heart failure patients are notorious for having high rates of readmission around the holidays and in the winter months when they may be eating a lot of canned soups, gravies, and broths. Case managers should caution them to be particularly careful about their diets during the holidays," she says.

Case managers should urge patients to write their weight down and to understand that gaining three pounds in a day or five pounds in a week is a signal that they are going to have problems, she adds.

Another indication that their condition may be exacerbating is when their belt or waistband is tighter than the day before or their ankles begin to swell.

"Case managers should remind patients that if it's harder to sleep at night or they're more short of breath, this could be an indication that they are getting in trouble and may need their diuretic dosage adjusted," she says.

Get a sense of the patient's condition by asking them specific questions about activities of daily living, Howie-Esquivel suggests.

For instance, ask if they can put their groceries in the cabinet, because raising the arms upward takes more energy that doing something that involves the lower body.

If you feel that a heart failure patient could benefit from exercise, talk to the physician about ordering an exercise program. "We know that exercise benefits patients with heart failure, but it's extraordinarily rare to find a heart failure patient involved in an exercise program. Being involved in an exercise program can't harm the patients, and it can help keep them out of the hospital," she says.

(For more information, contact Jill Howie-Esquivel, PhD, RN, FNP, e-mail: jill.howie-esquivel@nursing.ucsf.edu; other resources include: The Heart Failure Society of America, www.hfsa.org. The American Heart Association, www.americanheart.org.)