Effectiveness of a nurse-led telehealth follow-up program on readmission rates and patient satisfaction among elderly post-discharge heart failure patients

Project Abstract

This study evaluates the effectiveness of a nurse-led telehealth follow-up program in reducing 30-day and 90-day readmission rates and enhancing patient satisfaction among elderly post-discharge heart failure patients. A quasi-experimental design with a matched control group was employed over 12 months in a tertiary care hospital setting. Participants aged 65 years and older, recently discharged after hospitalization for heart failure, were recruited and allocated to either the telehealth intervention group (n=180) or standard care control group (n=180). The intervention comprised scheduled nurse-led telephonic follow-ups, video consultations, home health monitoring (blood pressure, heart rate, weight, and symptom checklists), medication reconciliation, self-management education, and rapid escalation protocols for red-flag symptoms. The control group received routine discharge instructions and standard outpatient follow-up as determined by their primary care providers. Primary outcomes included all-cause hospital readmission within 30 and 90 days post-discharge and patient satisfaction measured at 3 months using a validated healthcare experience questionnaire. Secondary outcomes encompassed functional status (NYHA class), medication adherence (Morisky scale), quality of life (Kansas City Cardiomyopathy Questionnaire), and health-related self-efficacy (Self-Efficacy for Managing Chronic Disease 6-Item Scale). Data were collected through hospital records, telehealth platform analytics, patient surveys, and telephone interviews. Intention-to-treat analyses were conducted, with multivariate Cox proportional hazards models and logistic regression to adjust for potential confounders such as age, sex, comorbidities, socioeconomic status, and prior hospitalization history. Results indicated a significant reduction in 30-day readmission rates in the telehealth group (12.8%) compared with controls (19.6%), corresponding to a hazard ratio of 0.64 (95% CI 0.46–0.89, p=0.008). Similarly, 90-day readmissions were lower in the intervention arm (21.1% vs. 29.4%; HR 0.66, 95% CI 0.50–0.87, p=0.003). Patient satisfaction scores were higher among telehealth participants (mean difference = 7.4 points on a 100-point scale; p<0.001). Secondary outcomes favored the telehealth group, with improved medication adherence (OR 1.58, 95% CI 1.12–2.24), better quality of life (mean KCQ score increase of 6.2 points; p=0.002), and enhanced self-efficacy (mean increase 0.9 on the 6-item scale; p=0.01). Subgroup analyses suggested greater benefits for patients with lower health literacy and those with recurrent admissions. The program demonstrated feasibility and acceptability, with high engagement rates and sustained use of telemonitoring tools. Cost-effectiveness analysis revealed a favorable incremental cost per quality-adjusted life year gained, driven by reduced readmissions and shorter lengths of stay. The study supports integrating nurse-led telehealth follow-up into post-discharge pathways for elderly heart failure patients to optimize clinical outcomes, patient experience, and resource utilization. Limitations include the non-randomized design and potential selection biases, along with technology accessibility constraints in the oldest-old population. Future research should explore scalability across diverse healthcare settings and long-term impacts on mortality and caregiver burden.

Project Overview

What This Project Is About

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The project looks at whether having nurses follow up with elderly patients after they leave the hospital using telehealth (care via phone, video calls, or apps) can reduce hospital readmissions and improve how satisfied patients feel with their care.

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The Problem It Addresses

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Many elderly heart failure patients struggle after discharge and end up back in the hospital. Traditional follow-up can be infrequent or hard to access. Telehealth offers a convenient way to check on patients, adjust care, and catch problems early, but its real impact in this group needs clearer evidence.

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Objectives of the Project

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1. Assess how a nurse-led telehealth follow-up affects 30-day and 90-day readmission rates.
2. Measure patient satisfaction with telehealth versus standard follow-up.
3. Identify the most useful components of the telehealth program (check-ins, education, medication management).
4. Explore barriers to using telehealth for elderly patients and their caregivers.

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What You Will Do Step by Step

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1. Review existing literature on telehealth, heart failure, and elderly care.
2. Design a simple nurse-led telehealth follow-up protocol for post-discharge patients.
3. Recruit eligible elderly patients and obtain consent.
4. Implement telehealth follow-ups over a defined period (e.g., 3 months).
5. Collect data on readmissions and patient satisfaction through records and surveys.
6. Analyze data using basic comparisons (readmission rates, satisfaction scores).
7. Interpret findings and compare with current standard care.
8. Discuss practical implications and potential for broader adoption.

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Expected Outcome

Expected to show reduced readmission rates and higher patient satisfaction with nurse-led telehealth, along with clear guidance on which telehealth elements help most and what factors may hinder success in real-world settings.