Transitional Care Home Visits: Outcomes Among Underserved Patients in a Heart Failure Clinic

Background Heart failure (HF) is a complex disease with a 59% five-year mortality rate, and significantly impacts quality of life (QOL). The prevalence of depression in patients with HF is three times higher than the general population. To compound these issues, underserved individuals often lack access to health care resources resulting in poorer outcomes and delayed treatments. Evidence supports the home visit (HV) approach to HF management as a method to promote positive outcomes and improved QOL. Yet, little is known regarding HV in this vulnerable population, specifically the outcomes associated with the timing of HV. Purpose The purpose of this quality improvement project was to evaluate if transitional care HV completed 14 days after hospital discharge impacted depression and functional status in underserved patients with HF over six months. Methods The setting was a nurse-led outpatient clinic. The two-year retrospective review included 45 participants who received a HV 14 days after hospital discharge. Demographic and clinical data collected included age, gender, race, ethnicity, and New York Heart Association (NYHA) class. Depression was measured by the Patient Health Questionnaire (PHQ)-9 survey. Functional status was operationalized using the Short Form (SF)-22 survey. Comparison of outcomes were measured at baseline and at three and six months. Descriptive statistics, t-test, and chi-square test were used to determine if any statistically significant differences existed between the groups. Results Statistically, no significant differences were observed in the demographic and clinical characteristics between the groups. The sample was predominantly African American (82%), mean age 50 years, and 55% males. Regarding NYHA class symptoms, 44% of all participants reported class III at baseline. At three months, 40% of all participants reported class I. By six months, 79% of participants in the HV 14 days reported class I. Only 1-3% of all participants described class IV throughout the six months. Mean PHQ-9 scores varied between the groups, but no statistically significant differences were observed by six months (HV 14 days = 5.62). T-test analysis did show statistically significant differences between the mean SF-22 physical health scores of the groups (43.3 versus 64.8), in which participants in the HV >14 days group showed improved scores by six months. Conclusions Project results showed that overall, HV timing did not significantly impact the health outcomes of underserved patients with HF over six months. Nevertheless, the results were clinically significant, as the home visitation program allowed clinicians and patients to benefit in ways that are not easily measured through surveys and statistical analyses. Home visiting provided an opportunity to strengthen the clinician-patient relationship. Clinicians were able to assess patient needs in the home environment and identify resources that benefited patients long-term. Lastly, the one statistically significant finding in the HV >14 day group suggests that there might be a learning period associated with more interaction with the healthcare team.