Feasibility of Using the Target: HF Telephone Follow-Up Tool in a Private Practice-Based Heart Failure Transitional Care Program

Abstract

Background: To reduce heart failure (HF) costs, the Centers for Medicare and Medicaid Services (CMMS) Hospital Readmissions Reduction Program (HRRP) cut reimbursements by 3% to the hospitals with high readmission rates. The American Heart Association (AHA)’s transitional care model program called Target: HF includes a structured telephone support (STS) tool, the AHA Target: HF telephone follow-up tool. It identifies barriers and breakdowns in HF self-management and encourages mechanisms to support HF patients.

Methods: This retrospective quality improvement Doctorate of Nursing Practice (DNP) project evaluated the feasibility of using the Target: HF telephone follow-up tool in a private cardiology practice, Old Pueblo Cardiology in Tucson, Arizona. Eligible patients were transitioning home following recent HF hospitalization. Project aims were to 1) describe patient willingness to participate in STS with rates of consent, contact, and tool completion, 2) calculate the telephone call time, and 3) assess self-management needs. Naylor’s Transitional Care Model and the Five-Stage Model of Naturalistic Decision Making were theoretical frameworks guiding this DNP project.

Results: A total of five patients participated. They averaged 84 (SD 8.245) years old, were 4.6 (SD 3.647) months post discharge, and five (100%) had normal left ventricular ejection fractions (LVEF). Patient engagement was 100% (n = 5) for consent, contact, and follow-up tool completion rates. The average call duration was 26.8 (SD 9.418) minutes. The greatest self-management needs were: none (0%) had a weight diary, one (20%) was not on fluid restrictions, weighed themselves on day 1 after discharge and knew their dry weight, three (60%) weighed themselves daily, engaged in exercise/daily physical activity, drank alcohol regularly, and knew symptom triggers to call to cardiologist. Medications were not always indicated.