Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure

Congest Heart Fail. Nov-Dec 2005;11(6):315-21. doi: 10.1111/j.1527-5299.2005.04458.x.


Multidisciplinary disease management programs for congestive heart failure have been shown to substantially reduce readmission rates, resulting in a reduction of costs. These interventions, however, have typically included changes in medical management, making it difficult to quantitate the key elements of a successful program involving education, discharge planning, and transitional care in the outpatient setting. The investigators utilized an experienced cardiac nurse educator to coordinate a targeted inpatient congestive heart failure education program coupled with comprehensive discharge planning and immediate outpatient reinforcement through a coordinated nurse-driven home health care program. The comprehensive intervention resulted in a marked reduction in 6-month readmission rates, from 44.2% to 11.4% (p=0.01). The average total cost saving for each subject in the interventional group was $1541, based on the decreased utilization of both skilled nursing services and home health care during outpatient follow-up. The costs to implement an inpatient education program were negligible, at $158 per subject. There was no difference in discharge medications or medical management protocols that would have influenced these results.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Case-Control Studies
  • Connecticut
  • Continuity of Patient Care / economics*
  • Cost Savings
  • Disease Management*
  • Geriatric Assessment
  • Heart Failure / diagnosis
  • Heart Failure / economics
  • Heart Failure / therapy*
  • Humans
  • Middle Aged
  • Patient Discharge / economics*
  • Patient Discharge / standards
  • Patient Education as Topic / organization & administration*
  • Probability
  • Program Development
  • Program Evaluation
  • Reference Values
  • Self-Help Groups