Nurse-Led Heart Failure Care Transition Intervention for African Americans: The Navigator Program

Not Applicable

Completed

Interventions: Behavioral: Heart Failure Self Care Support
Other: Usual heart failure care

Brief Summary: Heart failure (HF) affects over 5 million Americans with HF morbidity reaching epidemic proportions. Annual rates of new and recurrent HF events including hospitalization and mortality are higher among African Americans. In this study, the investigators are testing an interdisciplinary model for heart failure care, with focus on enhancing self management and use of telehealth, which has significant potential to improve self management and outcomes.

The main purpose of this study is to learn how to help African Americans with heart failure care for themselves at home. We hope to find out if a team including a nurse and community health navigator using a computer telehealth device can help people with heart failure stay healthier. The team will help people with heart failure to manage their medication, monitor their symptoms and weigh themselves every day after they leave the hospital. The team will also help people with heart failure learn to solve problems that may keep them from following their treatment plan.

Recruitment & Eligibility

Inclusion Criteria

Exclusion Criteria

cannot speak or understand English
severe renal insufficiency requiring dialysis
acute myocardial infarction within preceding 30 days
receiving home care services for HF post discharge
legally blind or have major hearing loss
screen positive for cognitive impairment on the Mini-cog at baseline
unable to stand independently on a weight scale (limited ability to participate in HAT system)
weigh more than 325 pounds (exceed scale capacity)
serious or terminal condition such as psychosis or cancer (actively receiving chemo or radiation)
pregnant

Arm && Interventions

Group	Intervention	Description
Heart Failure Self Care Support	Heart Failure Self Care Support	The goal of the Heart Failure Self Care Support Intervention (Navigator Program), delivered by a nurse and community health navigator team over 3 months post discharge from the index hospitalization, was to improve care transitions by providing patients with tools and support that promote knowledge and skills for HF self care as they transition from hospital to home. The multifaceted Navigator Intervention included the following intervention components: HF home automated telemonitoring support, medication and symptom self management, patient-centered record, HF care follow up, and activation of key supporter.
Usual Heart Failure Care	Usual heart failure care	Usual care for HF patients included the following: 1) Referral to HF clinic if the patient has no usual source of HF outpatient care, 2) HF patient education by HF care coordinator (advanced practice nurse), and 3) HF self care guide. All participants were treated by their usual source of HF care in the usual manner.

Primary Outcome Measures