Educating patients in how to effectively manage congestive heart failure at home presents holistic and non-pharmaceutical challenges for skilled home health nurses. Diet (in particular sodium intake), fluid intake, energy conservation and elevation of the lower extremities all play an important part in preventing acute exacerbation of CHF in addition to medications.
A primary issue involves dealing with health care illiteracy. This is when the patient doesn’t have a clue or understand the cause-and-effect relationships between salt or sodium intake and edema, the names, actions, and purpose of medications, and the need to establish new and improved habits for preventing acute illness. Finally, understanding the signs and symptoms of acute CHF and when to report to the PCP in order to regain control and prevent hospitalization and complications. When patients don’t know what they don’t know, they won’t ask questions, they won’t retain important information and they won’t know when and how to seek help before it becomes urgent. This is health care illiteracy. It is quite often mistaken for non-compliance.
Nurse practitioners were finally given the go-ahead from the CARES ACT to order and oversee skilled home health care. This issue has been debated in Congress for years, and finally with the public health emergency (PHE) presented by COVID 19, an emergency waiver paved the way to making this a permanent reality. NPs can help to make a huge difference in managing CHF long term by working with skilled home health care to spend quality time educating patients and helping them to establish a pattern of behavior to prevent exacerbation and complications. The NP needs to learn how to best utilize home health care to help with his/her patients. And home health staff should utilize the partnership to build and carry out an effective plan of care that helps reduce exacerbations and hospitalizations.
Building new habits takes time
Science tells us that it takes a minimum of 21 days to create or break a habit. Patients aren’t going to go to their practitioner’s office daily for 21 days. And who’s going to see what they actually do at home? Skilled home health nurses and therapists can make intermittent visits to educate patients and assess their knowledge, retention and success with the information. By going into the home and actually seeing the patient’s habits and lifestyle, a plan can be made to help the patient adapt to a new set of rules in order to manage many chronic illnesses including CHF. CHF was one of the first clinical pathways developed by/for home health clinicians more than 2 decades ago. Perhaps it should be reviewed and renewed for this rapidly growing and aging population.
One of the obstacles to success in home health is the attitude that the patient has had chronic CHF for a long time and been on these medications forever, so how can I as a home health nurse change this? He should know it all by now. This may be true, but often it’s only a part of the story. The patient has no clue because he was only given a diagnosis, a pamphlet to read, and a prescription. He has no idea how to fill in the blanks, he never took any science or medical courses to learn on his own how the human body works, what causes CHF, and how he needs to treat it. Why it’s chronic and the meds aren’t “curing him.” Just “take these meds, avoid salt and call if you gain over 5 lbs in one day.” Next time he sees a doctor, he’s in the ER or MICU with 4 plus pitting edema and so short of breath he cannot even gasp for air fast enough. He has no idea how this happened and why. Poor management of even chronic CHF may not be due to non-compliance, but rather to poor patient education and health care illiteracy.
Investigate and find out why management is poor
Learn more about heart diseases through CEUs and understand how to use the information to educate your patients. Accepting the fact that many CHF patients with post-acute care episodes are likely going to need skilled home health care following the hospitalization and starting from scratch with patient education will likely be the most important intervention. Start with what the patient knows or thinks he knows. What are the names of his medications and why is he taking them? Most likely he knows the diuretic such as Lasix and that it makes him urinate all night long, so he doesn’t sleep well. So, does he skip doses? How does he deal with this inconvenience? Ask his spouse? Does he really take the Lasix? Spend a few minutes to observe him making a meal for himself, sitting in his recliner chair and watching TV or napping. Does he have a clue about energy conservation, or his he wearing himself out just trying to get the ingredients to make the sandwich, much less get it to the table or eat it? Did he really just open a can of highly salted soup? Does he sit in his recliner with his feet hanging? Or does he recline all the way? Does he need a walker or a cane to make ambulation safer and easier? What about any other medications? Does he know what they do and why?
Does he weigh himself daily and keep a log? Check the log and review the numbers with him. Is it accurate and complete or has he skipped multiple days? Does he understand the signs and symptoms of pedal and abdominal edema, shortness of breath – even at rest, fatigue, difficulty concentrating, increased nocturnal urination (even without diuretics), rapid and irregular heart rate, nausea, lack of appetite, persistent cough and wheeze, chest pain, fainting or severe weakness? Does he understand when to notify his PCP and when to seek emergent care? Does he have co-morbidities such as COPD, kidney disease or diabetes? Are these managed and does he understand what those medications do, and how to manage the condition? Does he understand the correlation with his CHF? It may take several visits to get through the entire routine and to establish that he has accepted this new routine into his lifestyle. Documenting carefully the specifics of the patient education and his progress towards measurable gains will ensure reimbursement. Provide specific information and document his unique responses. Don’t just use the canned check boxes. Use patient quotes to show the gains. Keep the NP or PCP informed and involved in the progress.
Involve the whole team to complete the POC
It’s important to help him start and maintain a regimen of daily weights, taking meds as ordered, elevating lower extremities, following dietary and fluid restrictions, as well as managing any co-morbidities. Look through the cupboards. Look at the labels and show him how to add up the sodium, the sugars, etc. Help him meal plan and include lessons in shopping for foods that improve his outcomes. Call in an OT to instruct in energy conservation and a PT for safety and an exercise plan to improve the deconditioning from being acutely ill and hospitalized. And perhaps an MSW to help with long term planning. If he’s a re-admit, work to understand how he got off track, why and help him understand how to get back on track and avoid that in the future. Focus your documentation to demonstrate the skilled need, goals and measurable gains. State clearly what failed and why and the re-education needed. Work with the NP or PCP to establish a new POC and improve the quality of life and outcomes for your patients.