Journal of Cardiovascular Nursing

Vol. 29, No. 2, pp 140Y154 x Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Transitional Care Programs Improve

Outcomes for Heart Failure Patients
An Integrative Review
Kelly D. Stamp, PhD, APRN, ANP-C; Monique A. Machado, RN, MSN, ANP-BC;
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Nancy A. Allen, PhD, ANP-BC

Background: Individuals with heart failure are frequently rehospitalized owing to a lack of knowledge
concerning how to perform their self-care and when to inform their healthcare provider of worsening symptoms.
Because there are an overwhelming number of hospital readmissions for individuals with heart failure, efforts
are underway to discover how they can be supported and educated during their hospitalization and subsequently
followed by a nurse after discharge for continued education and support. Purpose: The purpose of this
integrative review was to critically examine the interventions, quality of life, and readmission rates of individuals
with heart failure who are enrolled in a transitional care program. The second aim was to examine the
cost-effectiveness of nurse-led transitional care programs. Conclusions: The results of this integrative review
(n = 20) showed that transitional care programs for individuals with heart failure can increase a patient’s quality of
life and decrease the number of readmissions and the overall cost of care. The types of interventions that were
most successful in decreasing readmissions used home visits alone or in combination with telephone calls. There is
a need for nurse researchers to address gaps in transitional care for heart failure patients by performing studies
with larger randomized clinical trials and measuring outcomes such as readmissions at regular intervals over
the study period. Clinical Implications: The Patient Protection and Affordable Care Act will change
reimbursement for heart failure readmissions and presents opportunities for healthcare teams to build transitional
care programs for patients with conditions such as heart failure. This integrative review can be used to determine
effective intervention strategies for transitional care programs and highlights the gaps in research. Healthcare
teams that use these programs within their practice may increase continuity of care and quality of life and
decrease readmissions and healthcare costs for individuals with heart failure.
KEY WORDS: heart failure, nurse-led interventions, readmissions, self-care, transitional care

C oronary heart disease (CHD) is the number 1

killer of individuals worldwide and is the most
costly medical condition in the United States.1,2 Coro-
nary heart disease is defined as a narrowing of the
small vessels that supply blood and oxygen to the
heart. Components of CHD, such as hypertension,
previous myocardial infarction, history of valvular
Kelly D. Stamp, PhD, APRN, ANP-C
Assistant Professor, William F. Connell School of Nursing, Boston
College, Chestnut Hill, Massachusetts.
Monique A. Machado, RN, MSN, ANP-BC
Adult Nurse Practitioner, William F. Connell School of Nursing,
Boston College, Chestnut Hill, Massachusetts.
Nancy A. Allen, PhD, ANP-BC
Assistant Professor, William F. Connell School of Nursing, Boston
College, Chestnut Hill, Massachusetts.
The authors have no funding or conflicts of interest to disclose.
Correspondence
Kelly D. Stamp, PhD, APRN, ANP-C, William F. Connell School of
Nursing, Boston College, 140 Commonwealth Ave, Cushing Hall
334F, Chestnut Hill, MA 02467 (stampk@bc.edu).
DOI: 10.1097/JCN.0b013e31827db560
insufficiency, diabetes, and obesity, place individuals
at risk for heart failure (HF).3 Heart failure is a com-
plex, chronic condition in which the heart muscle
becomes weakened and loses its ability to pump oxy-
genated blood to meet the body’s metabolic needs.4 It
affects about 5.8 million individuals, with associated
health expenditures estimated at $33.7 billion in the
United States.5 Furthermore, HF has been estimated
to affect 10 per 1000 individuals after 65 years of age
and 1 in 5 will develop HF after 40 years of age.6,7
Readmission Rates for Heart
Failure Patients
Readmission rates of HF patients are an area of great
concern because HF is the leading cause of hospital
admissions and readmissions in patients older than
65 years.8 More than 2.5 million Medicare beneficiaries
were hospitalized for HF from 2001 to 2005, and 1 in
10 died within 30 days of hospitalization.9 The Cen-
ters for Medicare and Medicaid Services (CMS) began

140

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tracking 30-day readmission rates for HF in 2009 as
part of the Hospital Readmission Reduction Program
of the Affordable Care Act.10,11 As reported by the
CMS (2009), the national average for HF readmis-
sions is 24.5%. Based on these statistics, CMS has a
goal to reduce hospital readmissions for HF by 20%
in the year 2013.11 Currently, one-fifth of Medicare
beneficiaries are readmitted within 30 days and 90%
of those readmissions are unplanned or preventable,
costing $17 billion.12
Quality of Life
Individuals with HF experience a multitude of symp-
toms such as shortness of breath, fatigue, and edema
that affect their quality of life (QOL). It has been
shown that patients with chronic HF may still have
major impairment despite optimal medical manage-
ment.13 Frequently experienced symptoms by HF pa-
tients such as shortness of breath and extreme fatigue
significantly restrict an individual’s ability to perform
self-care and daily activities, which greatly affects their
QOL.13Y15
National Cost and Burden of Heart
Failure Care
Heart failure is one of the most costly diagnoses in the
United States. The National Heart Lung Blood Insti-
tute (2010), reported $167.4 billion in direct costs of
cardiovascular disease and $119.2 billion in indirect
costs of mortality. Because HF is the most common
diagnosis of hospitalized patients 65 years or older16
and it is one of the most costly diagnoses for Medi-
care, the Hospital Readmission Reduction Program
plans to use the readmission data to reduce Medicare
base reimbursements to underperforming hospitals by
1% in 2013, 2% in 2014, and 3% in 2015. This will
affect inpatient services provided for all diagnosis-
related group readmissions within 30 days of an HF
admission.11
What Is Transition of Care?
Previous literature has clearly shown that patients lack
support from healthcare teams especially when tran-
sitioning from hospital to home.17 Transitions in care
refer to patients transferring from a hospital to home.
The transition points are vulnerable areas that con-
tribute to high healthcare spending and lapses in quality
and safety and are associated with increased rates of
hospitalization.17 According to the American Geriatrics
Society,18(p30) transitional care refers to the ‘‘actions
designed to ensure coordination and continuity of health-
care as patients transfer between different locations.’’
The Patient Protection and Affordable Care Act also
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Transitional Care Programs for Heart Failure Patients 141
acknowledges transitions as a barrier to quality care and
has initiated the Community-Based Care Transitions
Program. The Community-Based Transitions Program
goals are to reduce hospital readmissions, test sustain-
able funding streams for care transition services, main-
tain or improve quality care, and document savings to
the Medicare program.19 Ideally, transitional care should
begin during admission and continue at home and con-
tain an element of communication between providers to
ensure continuity. Most transitional care programs go
beyond education alone to include the nurses’ role in
coordinating multidisciplinary referrals based on the pa-
tient’s needs, communication among the inpatient team
members as well as home care personnel, and developing/
implementing tailored care plans that include patient and
family education, medication management/titration,
and increasing the patient’s activity levels/functional ca-
pacity. The purpose of this integrative review was to
critically examine the effects of nurse-led transitional
care interventions on hospital readmissions, QOL, and
cost-effectiveness of these types of programs for HF
patients and the healthcare system.
Methods
This integrative literature review examines and sum-
marizes previous research by drawing conclusions from
separate studies that are believed to address related
topics.20 The updated integrative review methodol-
ogy of Whittemore and Knafl21 was used to conduct
this integrative research review, which includes 5 re-
view stages: problem identification, literature search,
data evaluation, data analysis, and presentation (eg,
manuscript).
Problem Identification Stage
The problem addressed in this review was formulated
by specifying the variable of interest and the appro-
priate sampling frame.21 The criteria used for including
an article in this review were English-only, peer-reviewed,
qualitative and quantitative research focusing on dis-
charge planning and follow-up of HF patients 18 years
or older.
Literature Search Stage
A computerized search of the literature was conducted
using PubMed, Cumulative Index to Nursing and Health
Literature (CINAHL), Ovid Medline, Cochrane, Proquest,
Web of Science, PychInfo, Embase, and Joanna Briggs
Institute databases. Multiple text combinations used in
the search included the following key words: HF, transi-
tional care, transition of care, discharge, hospital to home,
readmissions, and continuity of care. The literature search
142 Journal of Cardiovascular Nursing x March/April 2014

intensity of each intervention (Table 1). High intensity

was defined as outpatient contact greater than or equal
to weekly visits; moderate intensity was defined as
once a month or more up to weekly visits; and low in-
tensity was defined as less than monthly visits. The
sample, study type, measures used, intervention, and
results are displayed in Table 2. The data displays
of Table 3 allowed for data comparison of the studies’
primary outcomes. The final phase in data analysis
was drawing and verifying conclusions,21 which is pre-
sented in the ‘‘Discussion’’ section.

Results
All studies included a transitional care intervention and
a control group receiving usual care with sample sizes
ranging from 70 to 1023 participants. The duration of
the transitional care interventions ranged from 10 days
to 18 months.

Types and Length of Interventions Studied

Fifty-eight percent of the studies were rated as high-
FIGURE. Process of inclusion and exclusion of studies used intensity interventions23,26,29Y34,37Y39 by the IRS, 21%
in this integrative review. were moderate intensity,27,28,35,36 21% were low in-
tensity,24,40Y42 and 1 study was not rated by the IRS
owing to the lack of information regarding the number
yielded 850 articles (see Figure). Sources reviewed were
limited to peer-reviewed articles, with no date range TABLE 1 Intensity Rating Table: Postdischarge
selected to assess the full extent of literature. Outpatient Contacts
Once per
Month
Data Evaluation Stage GOnce per or More Weekly
Month (Moderate (High
Duplicate articles were discarded initially, then titles
(Low Intensity) Intensity) Intensity)
and abstracts were reviewed for content. Studies that
were not in the English language and did not specifically Anderson et al23 X
Atienza et al24 X
have an intervention both predischarge and postdischarge Blue et ala,25
with HF patients were excluded. The methodological DeBusk et al26 X
quality of each study was evaluated using the integrative Harrison et al27 X
literature review instrument of Smith and Stullenbarger.22 Jaarsma et al28 X
It was determined that articles scoring less than an av- Jaarsma et al29 X
Kwok et al30 X
erage of 20 points of a possible 48 points were excluded Laramee et al31 X
from the review. Three independent reviewers rated the McDonald et al32 X
remaining 23 articles, and 3 additional articles were dis- McDonald et al33 X
carded for low quality ratings. Naylor et al34 X
Nucifora et al35 X
Rich et al36 X
Rich et al37 X
Data Analysis, Presentation, Display Russell et al38 X
Stauffer et al39 X
The next step in data analysis involved data display, Stewart et al40 X
which consisted of converting the data from extracted Stewart et al41 X
sources into a display around variables or subgroups.21 Williams et al42 X
We standardized and described the intervention dose
This table demonstrates the number of patient contact each study
as the number of visits over a 1-month period. An in- intervention implemented.
tensity rating scale (IRS) was designed to identify the a
Intervention details not available.

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of encounters by the authors.25 Three34,37,43 of the
high-intensity interventions included more than 1 visit
during hospitalization as part of the transitional pro-
gram, whereas 7 studies26,29Y33,38,39 did not specify
the number of inpatient visits. In 1 of the 20 studies
reviewed, the duration of the intervention was not
clearly identified.25,42 The IRS did not take into ac-
count the duration of the intervention. For example, 1
intervention consisted of 1 contact per month, which
was classified as moderate intensity per the IRS even
though it was only a 10-day intervention, which was
a short intervention in comparison with the other stud-
ies.28 Fifteen of the 20 studies (75%) reviewed were com-
posed of a multidisciplinary intervention (collaboration
between nurses, dietician, physical therapist, physician,
occupational therapy, social worker) while the patient
was inpatient or outpatient or both.24Y26,29Y38,40,41
The types of transitional care interventions varied be-
tween education only25,35Y37 or education with
counseling, 24,26,29Y34,38,40,41 medication titra-
tions,24,26,30,32Y35,41 progressing activity levels,41 visits
by the dietician,29,31Y33,36,37 physical therapist, and/or
occupational therapist.31,38
Readmissions
Of the 20 studies included in this review 19 measured
readmission rates as their primary endpoint. The
timing of measured outcomes was 30 days,32,38,39
90 days,31,33,36,37 18 weeks,42 6 months,23,30,35,40,41
9 months,28 1 year,24Y26,34 and 18 months.29 Ten of
the 19 studies showed significant improvements in the
intervention versus control group.23Y25,33,34,37Y41 Stud-
ies that yielded significant results primarily consisted
of interventions that had intensive, tailored multidisci-
plinary nurse-led inpatient education and home care
follow-up within 72 hours after discharge. The inpa-
tient interventions, on average, were composed of edu-
cation and counseling of both patient and family by a
multidisciplinary team as well as securing follow-up
appointments with the primary care physician or cardio-
logist before the patient’s discharge. The postdischarge
interventions consisted of telephone contact, home visits,
or a combination of both. The frequency of the home
visits intervention ranged between 1 and 20 visits over
the designated study period. Five studies with a com-
prehensive transitional care intervention had nonsig-
nificant differences in the readmission rates among
groups but reported that individuals randomized to
the usual care groups received a high level of standard
care, which possibly narrowed the differences between
groups.26,28,29,32,35 Other authors reported the need
for increased training of the interventionist in provid-
ing HF education and counseling as well as more care
coordination and follow-up appointments with the
providers.30,31 Study designs were classified as random-
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Transitional Care Programs for Heart Failure Patients 143
ized control trials,24,25,28,33,34,37,40,41 prospective,39 quasi-
experimental,23 or retrospective observational.38
Three of the 19 studies had a primary endpoint of
30-day hospital readmissions. Of these 3 studies, 2 re-
ported a significantly lower readmission rate for the
control group (43%, P G .01, Russell et al38; and 48%,
odds ratio, 12.6; 95% confidence interval [CI],
7.4Y17.8, Stauffer et al39). The study with nonsig-
nificant findings had no deaths or readmissions for
participants in either the intervention or the control
group.32 Two of the 4 studies that measured read-
missions at 90 days reported significant findings.33,37
Of the 4 studies, 1 focused on the patient’s being clin-
ically stable with tight medicinal control before dis-
charge from the hospital and during clinical follow-up.
This intervention resulted in readmission rates of
25.5% for the control group versus 3.9% in the inter-
vention group (P G .01).33 The second study had in-
tensive education and multidisciplinary follow-up
before discharge and between 6 and 20 home care
visits based on the patient’s need over a 6-week period
(P = .01; 95% CI, 2.8Y17.4).37 These studies were
rated as high intensity on the IRS. One study that had
nonsignificant findings was rated as high intensity,31
and the other, as moderate intensity.36 Both studies
provided education before discharge; however, the dif-
ference was the type of intervention used, telephone31
versus home visit.36 The high-intensity intervention used
telephone follow-up, whereas the moderate-intensity
intervention used home visits.
Five studies measured unplanned readmissions at
6 months; however, only 3 showed significant differ-
ences between the intervention and control groups (P =
.01; P = .03; P = .05, respectively).23,40,41 One of the
3 studies with significant results were rated as high
intensity23 and 2 were rated as low intensity40,41 on
the IRS owing to the difference in the number of home
visits and contacts made to the participants. The first
of the 2 studies with nonsignificant findings used a
combination of monthly nurse home care visits and
as-needed telephone contact (rated as high intensity on
the IRS)30 and the second study was rated as a
moderate intensity intervention, which involved tele-
phone contact plus clinic visits at 3 different time inter-
vals (15 days and 1 and 6 months).35
Four studies24Y26,34 measured readmissions at 1 year,
of which 3 studies24,25,34 showed significant results.
All 4 studies were randomized controlled trials. Blue
et al25 found that the risk of hospital readmissions was
reduced by 62% in the intervention group. Atienza and
colleagues24 showed a significant reduction in read-
missions by 16% (95% CI, 4%Y28%; P = .004) in
the intervention group as compared with the control,
which was similar to Naylor and colleagues,34 who
found a lower readmission rate and deaths at 1 year
(intervention, 47%, vs control, 61.2%; P = .01). The
 TABLE 2 Summary of Transitional Care Studies Reviewed
Authors Sample Study Type Endpoint(s) Intervention Results
Anderson et al23 N = 121 Quasi-experimental Primary: readmissions Inpatient At 6 mo, the intervention group had an
IG: n = 44 at 6 mo Formal, individually targeted 1-h-long 11.4% readmission rate, compared
UC: n = 77 Secondary: cost patient education provided by cardiac with the 44.2% readmission rate in
Men: n = 46 nurse within several days of hospitalization the control group (P = .01).
Women: n = 75 30-min dietician interview and instructions Hospital cost for each intervention
with follow-up visit before discharge subject ($158): Average 6-wk home
30-min physical therapy visit with health cost per subject was $1541.
15-min follow-up visit before discharge The total cost savings for each
Outpatient intervention subject was $67 804.
6-wk home care clinical pathway
allowing for 6Y20 visits from cardiac
trained home care nurses
Telephone interview within 2 wk of
discharge by nurse case manager
Atienza et al24 N = 338 Randomized Primary: hospital Inpatient Readmissions
IG: n = 164 controlled trial readmission at 1 y Phase 1: intense patient/family The IG had a readmission rate of
144 Journal of Cardiovascular Nursing x March/April 2014

UC: n = 174 Secondary: QOL, cost education by cardiac nurse prior 11.4% compared with UC group,
Men: n = 203 to discharge Cost which had a rate of 44.2% (P = .01).
Women: n = 135 Outpatient The overall cost of care was reduced
Phase 2: PCP appointment within 2 wk by approximately $2338 per patient
of discharge in the IG.
Phase 3: follow-up visits to outpatient HF QOL
clinics scheduled every 3 mo There was significantly higher
QOL in the IG (P = .01) at 1 y.
Blue et al25 N = 165 Randomized Primary: readmission Inpatient Readmissions/deaths were reduced by
IG: n = 82 controlled trial rates and mortality Patient education about HF and 28% in the IG (P = .0004).
UC: n = 75 at 1 y treatments
Men: n = 95 Optimization of treatment (drugs, diet,
Women: n = 70 exercise)
Provide psychological support
Outpatient
Home visits supplemented by telephone
contact with RN
Number of encounters not documented
by authors
DeBusk et al26 N = 390 Randomized control Primary: all-cause Inpatient There was no difference between groups
IG: n = 199 trial readmission at 1 y 1-h HF education session from baseline to 1 y (P 9 .02;
UC: n = 191 Outpatient CI, 0.84 [0.56Y1.25]).
Men: n = 236 Weekly nurse telephone calls for 6 wk,
Women: n = 216 biweekly for 8 wk, monthly for 3 mo,
bimonthly for 6 mo, and as needed

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(continues)
 TABLE 2 Summary of Transitional Care Studies Reviewed, Continued
Authors Sample Study Type Endpoint(s) Intervention Results
27
Harrison et al N = 192 Randomized Primary: readmission Inpatient At 12 wk after discharge, 31% of UC
IG: n = 92 controlled trial rates, QOL, symptom Evidence-based education (Partners in Care patients had been readmitted
UC: n = 100 distress for Congestive Heart Failure) by nurse compared with 23% of transitional
Men: n = 105 Nursing transfer letter to the home care care patients (P = .26).
Women: n = 87 nurse detailing clinical status and At 6 wk after discharge, overall MLHFQ
self-management needs scores were better among the
Outpatient transitional care patients than among
Telephone outreach from the hospital UC patients (P = .002).
nurse within 24 h of discharge
Community nurse visit minimum 2 visits
in 2 wk postdischarge
28
Jaarsma et al N = 179 Randomized Primary: readmissions, Inpatient Readmissions: There was no significant
IG: n = 84 controlled trial self-care ability, Nurse assessment during hospitalization, difference in readmissions between
UC: n = 95 behavior, and education, and support. Provided groups at 9 mo (P = .096).
Men: n = 103 resource utilization card of warning symptoms and
Women: n = 76 discussed discharge
Outpatient
Telephone call by nurse 1 wk
after discharge
1 home visit by nurse
Jaarsma et al29 N = 1023 Randomized control Primary: readmissions, Inpatient There were increased readmissions in
IG (basic support): trial mortality Visit by HF nurse for education the 2 IGs (41% and 38%) compared
n = 340 and support with the control group (42%) (P = .73;
IG (intensive support): Outpatient P = .52, respectively).
n = 344 Basic support: scheduled additional
UC: n = 339 outpatient via clinic to visit HF nurse
Men: n = 637 Received education and a number to
Women: n = 386 call for changes in symptoms
Intensive support: basic support plus
weekly phone contacts and 2 home
visits by HF nurse. Visits with
physiotherapist, dietician, and social worker
Kwok et al30 N = 105 Randomized Primary: readmissions, Inpatient Readmissions
IG: n = 49 controlled trial cost at 6 mo Education and support by nurse There was no difference between
UC: n = 56 Outpatient groups (P = .233).
Men: n = 47 Nurse visit within 7 d after discharge Cost
Women: n = 58 Weekly nurse visits  4 wk, Total public health costs were lower
then monthly in the IG than the UC group ($5229
Telephone calls for those refusing vs $20 916; P = .048).
home visits

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(continues)
Transitional Care Programs for Heart Failure Patients 145
 TABLE 2 Summary of Transitional Care Studies Reviewed, Continued
Authors Sample Study Type Endpoint(s) Intervention Results
31
Laramee et al N = 287 Randomized Primary: readmissions, Inpatient Readmissions
IG: n = 122 controlled trial cost at 90 d Education by an HF nurse There was no difference among
UC: n = 112 Outpatient groups (P = .49).
Men: n = 156 Patient and family education at weeks Cost
Women: n = 131 1Y4, 6, 8, 10, and 12 There was no significant difference in
cost among groups at 12 wk (P = .31).
McDonald N = 70 Randomized control Primary: readmission Inpatient Readmissions: There were no deaths or
et al32 IG: n =35 trial at 30 d Optimal medical management and readmissions in 30 d.
UC: n = 35 teaching before discharge
Men: n = 47 Outpatient
Women: n = 23 Telephone contact 3 d after discharge
and weekly thereafter for 12 wk
except weeks 2 and 6 (clinic visits
instead of telephone contact).
Number to call if symptoms occurred
McDonald N = 98 Randomized control Primary: readmission Same McDonald et al32 Readmissions were significantly greater
146 Journal of Cardiovascular Nursing x March/April 2014

et al33 IG: n = 51 trial at 90 d in the UC group (25.5%) compared

UC: n = 47 with the IG (3.9%); (P G .01).
Men: n = 65
Women: n = 33
Naylor et al34 N = 239 Randomized Primary: readmissions Inpatient Readmissions
IG: n = 118 controlled trial and death at 52 wk Initial APN visit within 24 h of hospital There were significantly fewer
UC: n = 121 Secondary: QOL, cost, admission and daily until discharge readmissions in the IG vs UC group
Men: n = 102 functional status Outpatient (47.5% vs 61.2%; P = .01).
Women: n = 137 Minimum of 8 APN home visits (1 within Cost
24 h of discharge). APN telephone At 52 wk, the IG had lower mean total
availability 7 d/wk costs (IG, $7636 vs UC group, $12
Weekly visits during the first month then 481; P = .002).
bimonthly visits during the second and Short-term improvements were
third months, additional APN visits demonstrated in overall QOL (12 wk,
based on patients’ needs P G .05) and physical dimension QOL
(2 wk, P G .01; 12 wk, P G .05).
Nucifora et al35 N = 200 Randomized control Primary: readmissions, Inpatient Readmissions: There was no significant
IG: n = 99 trial mortality at 6 mo Education and support by a nurse difference between the IG and
UC: n = 101 Outpatient UC group.
Men: n = 123 Nurse telephone follow-up 3Y5 d
Women: n = 77 after discharge
Nurse available by telephone 24 h/d
for questions
Outpatient visit by MD at 15 d and 1
and 6 mo and study nurse education

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 TABLE 2 Summary of Transitional Care Studies Reviewed, Continued
Authors Sample Study Type Endpoint(s) Intervention Results
Rich et al36 N = 98 Randomized pilot Primary: readmission Inpatient Readmissions: The IG patients
IG: n = 63 study at 90 d Intensive nurse-led education every day readmitted 33.3% compared with UC
UC: n = 35 Dietary teaching group (45.7%; OR [CI], 0.73
Men: n = 45 Medication review and social work visit [0.44Y1.20]).
Women: n = 53 Outpatient
3 home visits 1 wk after discharge
Home visits according to Federal Home
Guidelines
Rich et al37 N = 282 Randomized Primary: readmission, Inpatient Readmissions
IG: n = 142 controlled trial mortality at 90 d Intensive nurse-led education using Readmission for HF was reduced by
UC: n = 140 Secondary: QOL, cost teaching booklet developed for 52.6% in the treatment group (54 vs
Men: n = 45 geriatric patients with HF 24 in the control group; P = .04).
Women: n = 53 Dietary education and assessment and Cost
instructions registered dietician The overall cost of care was higher in the
Visit with social services for discharge control group by $460, or an average
planning and care. of $153 per patient per month.
Analysis of medications by geriatric QOL
cardiologist QOL improved in both groups;
Nurse home visit within 48 h of however, there was a significant
discharge improvement in the treatment group
Outpatient (P = .001).
3 home visits at first week of discharge
Home visits per Federal Home Guidelines
Russell et al38 N = 447 Retrospective Primary: readmissions Inpatient Readmissions: IG subjects had a lower
IG: n = 223 observational trial at 30 d HF education and referrals by a 30-d readmission rate (43%; P G .01)
UC: n = 224 multidisciplinary team than the UC group did.
Men: n = 194 Outpatient
Women: n = 253 Nurse visit and/or telephone call within
first 2 wk of discharge
Number of contacts not provided,
however tapered contacts within the
second 2 wk
Stauffer et al39 N = 140 Prospective study Primary: readmissions Inpatient Readmissions
IG: n = 56 design at 30 d, cost Education by APN There was a significant decrease in
UC: n = 84 Outpatient readmission by the IG vs UC group
Men: n = 62 APN visit within 72 h of discharge at 30 d (43%; OR [95% CI], 12.6
Women: n = 78 [7.4Y17.8])

(continues)

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Transitional Care Programs for Heart Failure Patients 147
 TABLE 2 Summary of Transitional Care Studies Reviewed, Continued
Authors Sample Study Type Endpoint(s) Intervention Results
8 APN home visits total Cost
APN available by telephone 7 d/wk There was significant reduction in cost
APN visit inpatient if hospitalization before and after intervention at 60
occurred d: OR (95% CI), $5729
($5076Y$6383) vs $5176
($4585Y$5768).
Stewart et al40 N = 97 Randomized control Primary: readmission or Inpatient Readmissions
IG: n = 49 trial mortality at 6 mo, cost HF education by a study nurse The IG had less readmission than the
UC: n = 48 Outpatient UC group did (P = .03).
Men: n = 47 Home visit by study nurse and PharmD Cost
Women: n = 50 1 wk after discharge The mean cost for IG was $3200
If needed, nurse contacted PCP for (95% CI, $1800Y$4600) vs $5400
further follow-up for UC group (95% CI,
$3200Y$6800).
Stewart et al41 N = 200 Randomized control Primary: readmission or Inpatient Readmissions
148 Journal of Cardiovascular Nursing x March/April 2014

IG: n = 100 trial death in 6 mo, HF education before discharge (same as IG had fewer readmission than UC group
UC: n = 100 cost, QOL UC participants) (P = .053).
Men: n = 124 Outpatient Cost
Women: n = 76 1 home visit 7Y14 d after discharge There was a nonsignificant decrease in
Diuretic management by nurse if needed cost for IG compared with UC
Telephone follow-up at 3 and 6 mo group (P = .16).
QOL
There was a significant difference
between IG and UC group at 3 mo
(P = .04), NS at 6 mo.
Williams et al42 N = 97 Quasi-experimental Readmission rates at Inpatient: Readmissions: IG participants did not
IG: n = 47 design 18 wk The CNS recruited participants within have fewer readmissions at 18 wk
UC: n = 50 24Y48 h of admission compared with UC group
Men: n = 52 HF CNS visited and educated regularly (P = .526).
Women: n = 45 throughout admission
Outpatient
Follow-up involved attendance at the
nurse-led clinic or home visits by
community HF nurse

Abbreviations: APN, advanced practice nurse; CI, confidence interval; CNS, clinical nurse specialist; HF, heart failure; IG, intervention group; MD, medical doctor; MLHFQ, Minnesota Living With Heart Failure
Questionnaire; NS, not significant; OR, odds ratio; PCP, primary care physician; QOL, quality of life; RN, registered nurse; UC, usual care.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 TABLE 3 Intervention Results Comparison Table
Intensity Duration of
Rating Intervention Readmission Reduction QOL Cost
23
Anderson et al High 6 wk At 6 mo, the IG had an 11.4% Not measured Hospital cost for each intervention subject
readmission rate, compared with ($158). Average 6-wk home health cost per
the 44.2% readmission rate in subject was $1541. The total cost savings for
the control group (P = .01). each intervention subject was $67 804.
Atienza et al24 Low 1y IG readmission rate of 11.4% Significantly higher QOL in the IG Reduction of $2338 per participant in the IG
compared with UC group rate of (P = .01) at 1 y
44.2% (P = .01)
Blue et al25 CNDF 1y 16% Not measured Not measured
DeBusk et al 26 High 1y 5% (NS) Not measured Not measured
Harrison et al27 Moderate 2 wk 8% (NS) Improvement at 6 and 12 wk Not measured
Jaarsma et al28 Moderate 10 d 10% Not measured Not measured
Jaarsma et al29 High CNDF 4% difference between UC and Not measured Not measured
intensive support
Kwok et al30 High 6 mo NS difference between IG and UC Not measured Significantly lower inpatient costs for IG vs
group (P = .233) UC group (P = .048)
NS difference in outpatient costs (P = .118)
Laramee et al31 High 12 wk NS difference between UC group Not measured NS reduction in cost between the UC group
and IG (P = .49) and IG at 12 wk (P = .28)
McDonald et al32 High 12 wk NS difference between UC group Not measured Not measured
and IG at 30 d
McDonald et al33 High 12 wk Decreased readmissions in the IG Not measured Not measured
vs UC group (P G .01) at 90 d
Naylor et al34 High 3 mo 13.7% Increased QOL at 12 wk (P G .05) Decreased cost in IG vs UC group at 52 wk
(P = .002)
Nucifora et al35 Moderate 6 mo NS difference between IG and UC NS difference at 6 mo Not measured
group
Rich et al36 Moderate 1 wk NS difference between IG and UC Not measured Not measured
group at 30 d
Rich et al37 High 90 d 52.6% Significant improvement between IG and Overall cost reduction of $460 with participants
UC group at 90 d (P = .001) in the IG
Russell et al38 High 4 wk IG had significantly lower Not measured Not measured
readmission than UC group
at 30 d
Stauffer et al39 High 3 mo 48% Not measured Significant cost reduction in IG
Stewart et al 40 Low 1 visit IG had less readmissions than UC Not measured Significant decrease in mean cost for IG vs
group (P = .03) UC group
Stewart et al41 Low 1 visit IG had less readmissions than UC Significant difference between IG and UC NS difference
group (P = .053) group at 6 mo (P = .04)
Williams et al42 Low CNDF 5.5% (NS) Not measured Not measured

Abbreviations: CNDF, could not be discerned from findings; IG, intervention group; NS, nonsignificant; QOL, quality of life; UC, usual care.

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Transitional Care Programs for Heart Failure Patients 149
150 Journal of Cardiovascular Nursing x March/April 2014
study that did not show significant differences in read-
mission rates between groups (32% vs 37%) used only
telephone contacts with 1 provider visit; however, it
was rated as high intensity on the IRS.26
Quality of Life
It has been clearly shown that if patients are not per-
forming self-care, the chronic symptoms of HF can
greatly affect the QOL of individuals living with this
disease.44 However, self-care can be achieved if proper
programs are in place that assist the patient with learn-
ing about their condition before and after hospital dis-
charge.44 For example, 6 of the 20 studies reviewed
measured the effects of a transitional care interven-
tion on the participant’s QOL.24,27,34,35,37,41 Five of
the 6 studies showed improvement in QOL despite the
wide differences in the intensity of the interventions
performed.24,27,34,37,41 Two of the 6 studies were rated
a high-intensity interventions,34,37 2 were rated as
moderate intensity,27,35 and 2 were rated as low inten-
sity24,41 by our IRS (see Table 1). Of the high-intensity
interventions, participants in the intervention group
were more likely to report stable or improved symp-
toms in comparison with the control group at 12 weeks
(P G .05, Naylor et al34; P = .001, Rich et al37).
Likewise, a study using a moderate-intensity inter-
vention found that the transitional care intervention
group had clinically significant improvements in their
reported health-related QOL at 6 (P = .002) and 12
(P G .001) weeks.27 The study of Nucifora and
colleagues35 was rated as a moderate-intensity interven-
tion; however, they found nonsignificant differences
among the groups in QOL at 6 months. Five of the 6
studies that measured QOL used the Minnesota Living
With Heart Failure Questionnaire,24,27,34,35,41 whereas
1 study used the Chronic Heart Failure Questionnaire.37
Cost of Transitional Care Interventions
Nine of the 20 studies measured cost of conducting a
transitional intervention program.23,24,30,31,34,37,39Y41
Six of the 9 studies showed significant cost savings in
the intervention groups.23,24,30,34,37,39 Total 60-day
direct costs of HF admissions at the intervention site
were compared with costs throughout the hospital sys-
tem and against current costs of standard care with
readmissions.39 Two studies found a cost improvement
by the intervention versus the control group (P = .002).24,34
One study had a total outpatient cost of $1541 per par-
ticipant. The authors used this information to estimate
costs for inpatient readmissions and found a savings
of $91 000 for the intervention group (P = .001).23
Similarly, the mean total costs of a 3-month interven-
tion with a 52-week follow-up for HF readmissions
yielded a decrease in readmissions by 6% and a cost
savings of $4845 per patient.34 One transitional care
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
program produced a net reduction in the use of hospital
resources by 51%, which resulted in an overall cost
reduction of $2338 per participant in the intervention
group.24 Furthermore, a cost analysis at 1 year showed
a 19% reduction in readmissions.24 When measuring
the overall cost of care for high-risk HF patients older
than 70 years, on average, the control group expenses
were $153 higher per participant each month com-
pared with the control group.37 Others found a sig-
nificant cost savings for the intervention group ($5229
vs $20 916; P = .048) owing to less emergency room
and inpatient hospital visits. However, there were non-
significant cost savings for outpatient visits at 6 months
($1457 vs $922; P = .118).30 Three studies showed a
decrease in hospital readmissions in the intervention
group; however, this difference was not statistically
different from the control group.31,40,41
Discussion
The purpose of this review was to synthesize the lit-
erature relating to transitional care programs for HF
patients and the effects of these programs on hospital
readmission rates, QOL, and cost-effectiveness. Com-
parisons of transitional care programs identified a gap
in the literature pertaining to transitional care in HF
patients as well as the great variability in the programs
that have been studied. Only 20 studies were found
that examined predischarge and postdischarge inter-
ventions for HF patients, demonstrating a gap in the
literature and the need for continued research. From
this review, it is clear that transitional programs have
the potential to reduce readmission rates, improve
QOL, and reduce cost. Interventions that had intensive
tailored, multidisciplinary nurse-led inpatient educa-
tion and counseling as well as home care follow-up
within 72 hours postdischarge and interventions com-
prising of home visits alone or in combination with
telephone follow-up were the most successful in yielding
significant reductions in readmissions, QOL, and cost.
Intervention Dose
The structure of the interventions reviewed in each pro-
gram varied greatly. The 1 consistent variable in all 20
studies was that patient contact occurred during hospi-
talization and after discharge. The inpatient interventions
was composed of 1 or more of the following components:
HF education by a nurse, dietary education, medica-
tion education/titration, and physical/occupational ther-
apy visits. In addition, inpatient interventions were
composed of care coordination among the healthcare
team members to ensure continuity of care and the con-
sultation of appropriate ancillary services. The out-
patient interventions included telephone interventions,
patient home or office visits, or a combination of both
physical and telephone contact. Eight studies did not

show a significant improvement in their readmission
rates.26,29Y32,35,36,42 The lack of significance between
the 2 groups could be because of the high level of
standard care that the usual care group received.
Duration of the interventions and length of time to
measure outcomes varied among the 20 studies. Be-
cause of the inconsistent duration of interventions and
outcomes measured, it is difficult to conclude which
intervention duration would be most effective for tran-
sitional care programs; however, the most successful
interventions were composed of frequent home visits
by a nurse and those that were tailored to the patient’s
specific needs and or deficits in knowledge. There were
significant decreases in reported hospital readmissions
at 30 days,38,39 90 days,33,37 6 months,23,40,41 and
1 year.24,25,34 Unfortunately, there was not sufficient
evidence available to evaluate if the benefits of the
transitional care programs decreased over time. Only 3
of the 19 studies in the current review measured rehos-
pitalizations at multiple time points.28,32Y34 However,
according to the data gathered in these 3 studies, there
were no significant differences among groups for re-
hospitalizations at any measured time point, with the
exception of the first time point immediately after the
intervention. The remaining 16 studies measured read-
missions at baseline and at the study endpoint only.
Future research should measure readmissions at greater
intervals throughout the study to tease out the bene-
ficial effects for HF patients enrolled in transitional
care programs over time. There was also variation in
educational preparation of the healthcare providers.
Two of the studies used advanced practice nurses to
deliver care,34,39 whereas others described specially
trained nurses and even nurses without any specific
HF training. Naylor and colleagues34 suggest that the
flexible protocols guided advanced practice nurses
and allowed them to address other comorbid condi-
tions that contribute to poor outcomes and readmission
of elderly HF patients. Comparing the educational back-
ground of healthcare providers and the effects on read-
mission rates, QOL, and healthcare costs did not reveal
that any one was more effective than another.
Quality of Life
Five of the 6 studies measuring QOL showed im-
provement after baseline. The earliest improvement was
measured at 6 weeks.27 Subsequent durations of im-
provement in QOL were seen at 12 weeks, 6 months,
and 1 year,24,27,34,37,41 with 12 weeks showing the
strongest impact on improving QOL during all mea-
surement intervals. For example, Naylor and col-
leagues34 measured QOL at baseline and at 2, 6, 12,
and 26 weeks, with the strongest impact on QOL at 12
weeks. Harrison and colleagues27 measured QOL at
baseline and at 2, 6, and 12 weeks, with the strongest
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Transitional Care Programs for Heart Failure Patients 151
impact at 12 weeks. Stewart and colleagues41 found a
significant improvement in QOL at 3 months, but not
at 6 months. Nucifora and colleagues35 found no sig-
nificant changes in QOL from baseline to 6 months
follow-up. Within this small sample of studies, it is
uncertain why the improvements occurred more often
at 3 months; however, these data suggest that it may
be beneficial to increase the length and intensity of
the postdischarge interventions to test for significant
effects. Future studies should continue to evaluate QOL
at regular study intervals to determine the types of inter-
ventions that are sustainable over time.
Cost
Three of the 9 studies included in this review showed a
reduction in cost in the intervention groups when com-
pared with usual care. This may indicate that when
readmissions are reduced in the presence of transi-
tional care programs, the overall cost to the healthcare
system at large is decreased. This reduction in costs
may occur with participants in the transitional care
programs because these programs help patients stay
well in their home longer, thereby reducing the need for
frequent readmissions. Two of the 6 studies did not
show a significant decrease in healthcare cost but did
have a significant decrease in readmissions.40,41 The 2
studies that failed to show a cost savings had these costs
offset by the increased cost of the home visits resulting
from the intensity of the postdischarge intervention.40,41
The recent CMS quality improvement policy re-
garding 30-day readmissions was not considered in the
studies reviewed. Therefore, they did not factor in lost
payments due to 30-day readmissions from the Medi-
care and Medicaid covered patients. Considering this
in future research may result in a more significant im-
pact on lowering costs especially because reimbursements
of all-cause readmissions within 30-days of a HF dis-
charge could decrease based on CMS regulations. These
reimbursement practices will also extend into other
medical diagnosis. Each study that demonstrated a re-
duction in costs also reduced readmission rates. These
findings reinforce the impact that readmissions have
on costs, specifically that lower readmission rates in
HF patients lowers costs. Only 2 of the interventions
measured 30-day readmission rates. Because of the up-
coming reimbursement policies to be enacted by CMS,
30-day HF readmissions as well as 30-day all-cause
readmissions should be studied more closely.
In summary, transitional care programs have the
potential to reduce readmissions, reduce cost of care
for HF patients, and improve QOL. The findings of
this review revealed that tailored inpatient education
and counseling along with tailored outpatient inter-
ventions consisting of home visits coupled with tele-
phone contacts can significantly reduce readmissions,
152 Journal of Cardiovascular Nursing x March/April 2014
What’s New and Important
h Nurse-led transitional care programs have the
ability to positively influence readmission rates,
quality of life, and healthcare costs.
h Home visits combined with telephone contacts may
be the most effective way to transition heart failure
patients from hospital to home.
h More research is needed in this area to study
sustainability over time.
increase QOL, and decrease cost in high-risk HF pa-
tients. However, more research must be completed to
evaluate the sustainability of a nurse-led transitional
care intervention for high-risk HF patients.
Limitations
Nineteen of the 20 studies measured readmission rates.
However, we were unable to account for the variability
of comorbidities within each sample of patients with
HF. The variability in acuity and comorbidities may
have affected and/or attributed to increased readmis-
sion rates regardless of the intervention performed. Of
the 20 studies reviewed, only 6 studies measured QOL,
which limits the generalizability of our findings for the
variable QOL. Second, the methods of measurement
used to analyze cost varied throughout studies, and a
majority of the studies did not use statistical analysis,
making it difficult to formulate any conclusions. In
addition, the studies that did perform cost analysis did
not examine the effects of the Patient Protection and
Affordable Care Act reimbursement policy that will come
into effect in the year of 2013. Furthermore, interventions
varied in the frequency of contact, intervention duration,
method of contact, education of providers, and timing
of when outcomes were measured. One study identified
the length of telephone conversations made between
providers and participants but no other study described
the average length of each patient contact. Lastly, it
was difficult to fully evaluate 1 study that did not detail
the components of their intervention.
Research Implications
To move the science forward in refining transitional
care interventions for patients with HF, future research
study designs and subsequent research reports need to
specifically address the following: frequency, interval,
duration, and content of the intervention; frequency
and duration of inpatient contact; timing of initial out-
patient contact post discharge; type of patient contact
provided; and level of provider used to implement the
intervention. Once these factors are described and have
demonstrated their effectiveness over time, researchers
should design and implement transitional care programs
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for HF patients in a ‘‘real world’’ practice setting to eval-
uate their effectiveness.
An additional aspect of transitional care is the health-
care team communication between settings. Details into
how transitional care information is transferred during
the intervention are vital to understanding how health-
care teams can improve continuity. Other critical in-
formation is the healthcare costs of transitional care
programs as well as financial consequences to the health-
care system. To demonstrate the full financial impact
that transitional care programs can have once CMS
reimbursement policies change in 2013, all-cause read-
mission rates should be measured at 30 days and com-
parative cost analysis performed.
Practice Implications
Nurses and other practitioners have the opportunity to
improve the transitional care process for HF patients
within their organizations. The Affordable Care Act
and the Administration on Aging45 provide easy-to-
use toolkits that help guide healthcare teams with de-
veloping the infrastructure necessary for improving the
effectiveness of transitioning individuals with chronic
illnesses from acute care facilities (hospital) to the com-
munity or nursing home settings. This toolkit supports
healthcare teams with reducing the occurrence of fre-
quent hospital readmissions and provides funding re-
sources to build successful transitional care programs.
Specifically, some of the topics covered are developing
policies and procedures, expected costs and billings,
how to appropriately staff the program to accomplish
your goals, how to measure for quality improvement,
building formal partnerships, and how to build your
reputation within the community. Furthermore, infor-
mation is available on the types of funding mechanisms
for transitional care programs including program an-
nouncements and grant application instructions.
Healthcare teams can use this integrative review to
understand the gaps in the literature and the types of
interventions that produce significant changes that will
reduce hospital readmissions, decrease healthcare cost,
and increase QOL in HF patients. This information,
coupled with the Administration on Aging’s toolkit
and grant opportunities, provides crucial information
to build a successful transition program designed to
achieve positive outcomes.
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