Category: Health and Health Care

7 - Improving Patient And Caregiver Engagement During The Transition Of Care To Improve Health Outcomes In Patients 65 Years And Older With Heart Failure.

Introduction: Heart Failure (HF) is challenging to patients, families, and healthcare providers because of the heavy symptom burden and frequent hospitalizations. About one million adults over 65 years of age are hospitalized for HF per year in the United States of America alone. Though post-discharge services to prevent readmission are increasing; the readmission rate is, however, not declining. The aims of the project were to improve self-management ability through patient engagement during admission and transitional period and to prevent unnecessary readmission and emergency department utilization post hospitalization.

Literature Review: Meaningful partnerships with patients and families are essential for achieving the federal government’s healthcare triple aims to improve quality of care, improve patient experience and reduce healthcare cost. Heart failure transition of care programs to improve health outcomes post hospitalization include common themes such as telephone follow up, education, self-management, social and psychological support. In studies of patient activation for self-management, positive relationships were suggested between the amount of knowledge, skill and confidence about handling chronic conditions, referred to as “engaged,” and the ability to manage care, promote health, and make better decisions affecting one’s condition.

Theoretical Framework: Patients must be empowered to become adequately informed, make healthcare choices, and adopt healthier lifestyles. Patient empowerment is achieved through collaboration among healthcare team, and in partnership with patients and family.

Methodology: The design for the project was descriptive pre-and post-intervention. The Patient Activation Measures (PAM) score level was used to categorize consented participants. A targeted improvement intervention based on the activation level was implemented. Data were analyzed quantitatively.

Results: Sixty-two and a half percent of patients who completed the three PAM surveys and had education interventions, had at least one level of increase in activation level. Eighty-seven percent of patients who completed the project did not get readmitted within 30 days of index admission.  All three patients with caregiver involvement remained out of the hospital for at least 30 days after discharge.

Discussion: The findings from this project support the ability of the PAM to identify a patient’s activation level, and to measure improvement following the project intervention. The 30-days HF readmission rate for the participants was also lower than the overall baseline rate for the hospital.

Conclusion: Improvement in self-management ability of HF patients 65 years and older, through patient engagement during the admission and transitional period could prevent unnecessary readmissions and emergency department utilization post hospitalization.


Oluremi O. Oriowo

Clinical Educator
Premier Health Learning Institute
Springboro, Ohio

Oluremi Oriowo is a Clinical Educator and Primary Nurse Planner for Continuing Education for Premier Health Learning Institute, Dayton Ohio. She received her Master of Science in Nursing with Healthcare Law focus in 2011 and her Doctor of Nursing Practice in Population Health Leadership in 2017 from Xavier University Cincinnati Ohio.