1. Can Nurses Assist Older CHF Patients With Self-Care? Sallie A. Alvarez NGR 5800 American Heart Association

2. Background  CHF can affect anyone but those at highest risk are elderly, African-Americans, smokers, overweight and men (“What is heart”, 2012).  Treatment involves close monitoring of diet, fluid intake, weight, medication and psychosocial support (What is heart”, 2012)  Sophisticated self-care is necessary to avoid hospital readmissions once patients are home (“What is heart”, 2012)  The elderly are the least able to be successful in self-care of CHF due to advanced age, progressive cognitive, physical and emotional health problems (Naylor, 2012).

3. Significance  CHF affects 5.7 million people in the U.S. (CDC, 2013)  CHF is the leading cause of hospitalizations in people aged 65 or over and costs the nation $34 billion/year (CDC, 2013).  The percentage of adults over 65 is expected to grow from 10%-17% by 2030 (Kelly, 2011).  It is forecasted that by 2030, an additional 3 million people with have CHF (Roger, et al., 2012).  It is estimated that 50% of hospital admissions for heart failure are preventable, meaning patient education can reduce readmissions (Naylor, 2012).

4. Problem  Elderly patients lack successful management of CHF in the post discharge phase and therefore are frequently readmitted into the hospital. Aim  To provide elderly heart failure patients with holistic and comprehensive support and care in the post discharge phase.

5. Naylor’s Transitional Care Model (Naylor, 2012)

6. Naylor’s Transitional Care Model  Provides patients and families with needed support during post discharge phase  Transitional Care Nurse (TCN) main point of contact during 2 month period following discharge  Home visits or phone calls 7 days a week for 2 months  Teaching to both patient and family in the home setting  Early identification of symptoms to avoid hospitalizations (Naylor, 2012)

7. Application of Theory  Identify at risk patients in the hospital  Develop individual care plan for patient/family  Daily visits/phone calls for 2 months  TCN will be main contact between providers, patient and family caregivers  TCN will teach early symptom identification and subsequent course of action, as well as diet, medication compliance and any other required intervention

8. References Centers for Disease Control and Prevention (CDC). (2013). Heart failure fact sheet. Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.html Department of health and human services, National Heart, Lung and Blood Institute. (2012). What is heart failure. Retrieved from: http://www.nhlbi.nih.gov/health/health- topics/topics/hf/ Kelly, M. D. (2011). Self-management of chronic disease and hospital readmission: A care transition strategy. Journal of Nursing & Healthcare of Chronic Illnesses, 3 (1), 4. Naylor, M. (2012). Advancing high value transitional care: the central role of nursing and its leadership. Nursing Administration Quarterly, 36 (2), 115-126. doi:10.1097/naq. 0b013e31824a040b Roger, V., Go, A., Lloyd-Jones, D., Benjamin, E., Berry, J. J., Borden, W., Bravata, D., & Dai, S. American Heart Association, (2012). AHA statistical update: Heart disease and stroke statistic-2012 update. Retrieved from http://circ.ahajournals.org/content/125/1/e2.full