Home Health Research Update: past, present, future

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Home Health Research Update past, present, future

• Christina Quinn, RN, DNS
• Post-Doctoral Fellow
• Emory University
• Nell Hodgson Woodruff School of Nursing
• Atlanta, GA

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Doctoral Dissertation TitleHome health nursing
patients symptom management strategies, and
their relationship to symptom status, quality of
life, and acute health service utilization

• Descriptive, correlational study
• Tested a model examining the relationships
  between HH patients and symptom management
  variables

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HHSM model from Dissertation
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Key Results from Model Development

• Direct effects
• three personal variables were predictive of
  family support gender, marital status, and
  perceived severity of illness.

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Key results contd

• Indirect Effects
• The independent variables gender, marital status,
  and perceived severity of illness together
  predicted how much social support a patient had
  and, with the mediating variable of
  family/community support, predicted quality of
  life and numbers of acute health service visits

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CHF and Home Care

• In a review of research studies r/t CHF Home
  Care, most of the responsibility of patient
  management fell to nurses where specialty care
  for CHF patients extended into the home
  environment (Fitzpatrick, 2000)
• Home Health Nursing has been associated with a
  lower rate of rehospitalization among persons
  with CHF (Martens, 2000)

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Impact of a chronic disease such as Heart Failure
Rehospitalization
Medication Compliance
Quality of Life
Communication with Nurse and/or Doctor
Functional Status
Dependence
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Interventions to Decrease Re-admissions
Improve QOL
Regular Checkups
Medication Compliance
Diet Weight
Communication with Nurse and/or Doctor
Exercise
Symptom Management
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CHF Home Health Pilot Study

• CHF home care patients
• Home visits
• Telephonic visits
• Standard teaching tool for nurses
• Notebook/Log patient participation

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CHF Patients

• Two groups of CHF patients
• Control group current method of care with
  questionnaires filled out at admission and
  discharge (5 patients)
• Intervention group a structured intervention
  with a mixture of home visits and telephone
  visits (15 patients)

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Inclusion Criteria

• Patients chosen after the OASIS had been
  completed by the RN
• CHF primary diagnosis
• Oriented to person, place, time
• Speak and read English
• Not enrolled in a cardiac rehab program
• Working telephone line

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Exclusion Criteria

• CHF as secondary diagnosis
• End Stage CHF as documented by MD
• CHF symptoms maintained by dobutamine

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Home Health Agency

• Rural agency (1 hour south of Atlanta)
• High volume of CHF patients
• Current unstructured treatment plan for CHF
  patients
• Interested in improving outcomes of care for CHF
  patients

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Unstructured Treatment Plan for CHF Patients

• April 2002 April 2003 (26 patients)
• 55 99 years
• 19 females
• 7 males
• 1-3 hospital admissions per patient
• Nursing visits ranged from 3-28 with an average
  of 11 or 12 per episode

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Description of Structured Intervention

• Once accepted into the study and signed consent
• These patients received digital scales, a blood
  pressure monitor, medication box, and log
  notebook
• Scales and medication box stay w/patient after
  discharge blood pressure monitor and log
  notebook collected by RN at discharge

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Description of Intervention-contd

• 9 week intervention
• Combination of home visits and telephone
  visits/interview
• Measures of symptoms, functional status and
  quality of life
• A standardized teaching tool for each nurse
  (developed by Researcher)
• Notebook/log for patient

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A Structured Intervention for CHF Patients
SUMMARY

• Weeks 1, 2, 4, 6, 9 Home visits by the nurse
  (eight total)
• Weeks 3, 5, 7, 8 Telephone interview by the Home
  Health nurse (four total)
• 3 months post discharge patients evaluated for
  readmission to agency or hospital

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Instruments Telephone/Home Interview

• Please circle if this is a home or telephone
  interview
• HOME or TELEPHONE
• Assessments made of comfort, SOB, Vital Signs
  etc.
• Nurse would ask patients to refer to Log Notebook
  during telephone interviews

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Instruments Log/Notebook

• Delivered to patients home during first week
• Used to keep track of VS, hospitalizations, MD
  visits, missed medications, and telephone calls
• Sample next slide

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Standardized Teaching Approach

• Each nurse was given a notebook designed as a
  flip chart
• Easy to use in the patients home
• Topics included definitions, symptom management,
  diet, medications, and warning signs of CHF

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Teaching GuidelinesPatients With Heart Failure
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Results Intervention Group

• Patient Statements enjoy use of Notebook/ Log
  most able to use scale and BP cuff in home
• Nurses Statements teaching tool very useful
  Notebook/Log helps keep track of all aspects of
  patient excited about improving patient care

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Rehospitalization Results

• Hospitalized during intervention
• 1 due to a fall
• 1 died during 7th week due to heart attack
• Hospitalized 3 months after intervention
• Three hospitalized 1 for MI, 1 for prostate
  surgery, 1 for a fall

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Summary of Intervention Study

• Favorably received by home care nurses, patients,
  and physicians
• Reduced emergent care and re hospitalizations
• Improved the organization of nursing care with
  CHF patients in this Agency
• Quality of life for the intervention group
  improved
• Use of telephone to solve problems validated
  previous research studies

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Current Home Health Study

• Theoretical perspective
• Interdependence Theory- a dyad level
  social-psychological theory
• A middle-range theory developed from Social
  Exchange Theory
• focuses on the nature of situations

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Specific Aims

• What is the relationship between family context
  variables and symptom management congruence in
  the heart failure patient/family member dyad?
• Which symptom management behaviors or family
  context variables are possible predictors of
  outcomes (QOL and health care utilization).

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Symptom management in Home Health

• Home Care focuses on Symptom Management
• Assessing, Educating, Managing, Promoting
  self-care, problem solving

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Role of the family

• Family members who are involved in symptom
  evaluation and response can alter the process the
  patient is going through (Goodlin, 2004 Maxwell,
  1997)
• Lack of cooperation between family and patient
  has been shown to lead to inaction when
  intervention was necessary
• (Maxwell, L. 1997 Quinn, J. 2005)

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Family Functioning

• Assessing family functioning allows the family
  unit to become the focus of symptom management
  strategies
• Partner Support Style can affect how couples cope
  with illness and make decisions on treatment

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Congruence Symptom Management

• Congruence of care between dyads has been
  limited
• Non congruence has been associated with higher
  levels of distress within the dyad (Lobchuk,
  1997)
• Pain intensity has been over estimated (Clipp,
  1992 Porter, 2002)
• Higher levels of fatigue anger in
  non-congruent dyads (Miaskowski, 1997)

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Congruence Decision Making

• HF patients and Family members need to be
  examined for congruence in decision making for
  symptoms experienced in heart failure

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Measuring Symptom Management

• HF patient and FM each complete
• 2 symptom assessment measures
• Heart Failure Symptom Survey (14 symptoms)
• (Pohzel, 2006)
• Self-Care of Heart Failure Index
• Recognition of shortness of breath edema w/
  responses (Riegel, 2004)

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Heart Failure Symptom Survey

• 1. In the last 7 days, have you had shortness
  of breath at rest? (scale 1-10)
• Frequency
• Severity
• Interference with physical activity
• Interference with enjoyment in life
• Action taken

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Self-Care of Heart Failure Index

•     The LAST TIME you had trouble breathing or
  ankle swelling,
• -how quickly did you recognize it as a symptom of
  heart failure?
• Think of a remedy you tried the last time you had
  trouble breathing or ankle swelling,
• - how sure were you that the remedy helped or did
  not help?

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Assessing Family Communication

• HF patient and family member
• 2 measures
• Family Assessment Device
• Partner Support Style (APO Questionnaire)
• Protective buffering, Overprotection, Active
  engagement

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McMaster Family Assessment Device (FAD)
(Miller, I et al., 1985)

• An assessment measure in families of persons with
  chronic illness.
• 3 subscales
• General Family Functioning
• Problem Solving
• Communication
• Scoring 4-point Likert Scale
• Higher scores indicating less effective family
  functioning (1 healthy family functioning 4
  unhealthy family functioning)

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Samples of FAD Questions

• 27 questions scale Strongly Agree -Strongly
  Disagree
• We dont often say what we mean
• We resolve most emotional upsets that come up
• We confide in each other
• We avoid discussing our fears and concerns

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Partner Support StyleAPO Questionnaire

• Patient and Partner version
• 19 questions scale 1(never) 5(very often)
• Active engagement My partner asks me how I
  feel
• Protective Buffering My partner tries to hide
  his/her worries about me
• Overprotection My partner continuously keeps an
  eye on me

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Measuring Outcomes

• Quality of Life
• Minnesota Living With Heart Failure Questionnaire
  (Rector, et al, 1995)
• Bakas Caregiving Outcomes Scale (Bakas, 2001)
• Health Care Utilization
• Rehospitalization or ED visits 30 60 days post
  research
• Obtained from patient report or HH chart

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Quality of Life

• Minnesota Living with HF Questionnaire
• 21 items
• To what extent has your HF prevented you from
  living as you have wanted to over the past month
  by
• making you rest throughout the day
• causing swelling in your ankles/legs

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Quality of Life

• Bakas Caregiving Outcomes Scale
• -an outcome measure for family members as
  caregivers in heart failure symptom management
• -16 items, -3, -2, -1, 0, 1, 2, 3
• As a result of providing care for my family
  member with heart failure
• my physical health ________
• my role in life_________

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Demographics to date

• Numbers of dyads (as of 7/31/07)
• - 40 dyads
• Demographics of dyads
• Age 56-85
• Gender __female, __male
• Ethnicity __Asian, __African-American,
  __Caucasian
• Education 6th grade 4 yrs college

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Preliminary Results

• Case 1
• 73 y/o African-American lives in a home with
  multiple family members HF dx for 3 yrs
• Daughter, 48 y/o, primary caregiver

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Case 1 contd

• FAD examples
• We avoid discussing our fears and concerns
• Patient- agree Daughter-disagree
• Making decisions is a problem for our family
• Patient- agree Daughter-disagree
• We confront problems involving feelings
• Patient-disagree Daughter-agree

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Case 1 contd

• APO
• My partner waves my worries aside
• Patient-quite often Daughter-now then
• When it comes down to it, my partner thinks she
  cannot leave my recovery to me
• Patient-quite often Daughter-does not

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Case 1 contd

• HFSS
• Shortness of breath at rest, with activity, and
  when lying down
• Patient-score of 10 for frequency severity
• Daughter-score of 5 for each
• Been depressed or feeling down
• Both gave a score of 8 for frequency severity

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Preliminary Results

• Case 2
• Patient-79 y/o Caucasian male
• Lives with spouse 83 y/o female

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Case 2

• FAD
• It is difficult to talk to each other about
  tender feelings
• Patient-agree Wife-disagree
• When we dont like what someone else has done,
  we tell them
• Patient-disagree Wife-agree

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Case 2

• APO
• My partner thinks that when he/she is not
  around, I will not follow the doctors
  instructions
• Patient-quite strongly Wife-does not
• My partner thinks I do not know what is right
  for me
• Patient-quite strongly Wife-does not

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Case 2

• HFSS
• Swelling in your feet, legs, or ankles
• Patient score of 2 for Frequency Severity
• Wife score of 0 for each
• Tired, lack of energy
• Patient score of 0
• Wife score of 5

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Future Research Ideas

• Enhancing CHF patient and family member
  congruence on symptom management through testing
  an intervention
• Design teaching tool specifically for caregivers
  of HF patients
• Design assessment guide for caregivers
• Use perspective taking theory when asking
  caregivers about patient symptom experiences

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Collaborators in Heart Failure Research

• S. Dunbar Family focused intervention to
  improve diet and medication adherence in HF
• R. Gary Exercise and cognitive behavioral
  therapy for depression in HF
• C. Reilly Fluid management in HF patients with
  implanted impedence devices

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• Questions?