Introduction: The growing number of patients with chronic heart failure has increased both the pressure on hospital resources and the need for community management of the condition. Because of the prevalence and expense of chronic heart failure, significant efforts have been made to develop home visit service that will improve clinical and financial outcomes.
Aims: This study attempts to identify the effectiveness of community home visit nurse-directed intervention in Oman in reducing hospital readmission rates among patients who are suffering from heart failure.
Methods: We conducted a prospective, clinical trial of the effect of community home visit intervention by a nurse on rates of readmission within 3 months and 6 months of hospital discharge. Patients with specific criteria were identified by the discharge planner and referred to the community nurses. After one week from the discharge date, patients were visited by the community nurses. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation, a review of medications and patients' adherence to it, and vigilant follow-up with early recognition of problems, as well as identification and management of patients' comorbidities.
Results: The primary outcome measure was achieved in the all patients (total of 54) who received the intervention in the first 3 months. Whereas, after 6 months it had been noted that 10 patients out of 54 was readmitted in the hospital. The reasons of readmission were different causes. There was a significant reduction in the readmission rate before and after the introduction of the intervention. For instance; 30 day readmission rate in single center before receiving the intervention was 27%, and after the intervention 15% (27 vs. 15, P < 0.01). On the other hand quality-of-life scores at 6 months improved more from base line for patients who received the intervention (P = 0.001). Because of the reduction in the hospital admissions, there was an improvement in the beds availability in Sohar Hospital medical wards.
Conclusion: A community home visit nurse-directed intervention can reduce the readmission rate among heart failure patients and improve patient's quality of life.