Transitional care for patients with congestive heart failureto reduce readmission rates

Abstract

Heart failure is a chronic disease that causes suffering. It affects patients activities of daily living, decreases quality of life and deteriorates health condition, both physically and mentally. Patients who are hospitalized with heart failure have a high risk of readmission. This article is intended to present guidelines for the care of patients with heart failure to reduce readmission rates by using the transitional care model that was developed by Melies et al. The model includes assessment of readiness, preparation for transition and role supplementation, in order to provide care for patients in the acute phase, during hospitalization, and prior to and after discharge. The nursing activities consist of the following: 1) during acute care, nurses should provide care for patients to prevent a life threatening crisis while in hospital, 2) patient care before discharge consists of assessment and record of basic health data, patient's and caregiver's readiness, environment, and risk of readmission. Nurses should also provide education and skills training in 6 aspects of care including diet and water intake, medical adherence, activity and rest, importance of daily weight monitoring,  what to do if the symptoms worsen and follow-up appointments, and 3) post discharge care can be conducted by telephone calls and home visits. Nurses play a crucial role in the care of patients in every phase of the disease in order to increase the quality of life of the patients, to reduce the chance of relapse and readmission, and to decrease the mortality rate from heart failure.