SummaryMassachusetts General Hospital and the University of California, San Francisco, developed a nurse-guided, patient-centered approach that combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse for unpartnered, elderly patients who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. A randomized controlled trial found that the program improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications but failed to reduce overall hospital readmissions.Strong: The evidence consists of a 247-participant RCT evaluating the program's impact on adherence to medical recommendations and readmissions.
Developing OrganizationsMassachusetts General Hospital Department of Nursing; University of California, San Francisco, School of Nursing
Massachusetts General Hospital is in Boston.
Date First Implemented1999
Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)
Problem AddressedBecause of the dramatic increase in self-care requirements after cardiac events, there is a tremendous need to build the capacity of unpartnered elders to better care for themselves after a major cardiac event.1
- Significant health problem: Cardiovascular disease is the nation’s single leading cause of death, and it tends to strike relatively late in life.1
- Lack of support system: Unmarried individuals over the age of 65 years old who lack in-home partner support have poorer health outcomes after a heart attack and coronary artery bypass graft (CABG) surgery than do elders with partners. Due to shortened inpatient stays, elderly, unpartnered patients may not have the time or opportunity while in the hospital to develop the knowledge and skills necessary to manage cardiovascular disease and its associated requisite lifestyle changes.1
- Cardiac rehabilitation impact: Current cardiovascular guidelines, moreover, stress the importance of participating in cardiac rehabilitation to reduce the risk of further acute episodes. However, most unmarried elders without in home support find it difficult, if not impossible, to participate in such rehabilitation programs.1
Description of the Innovative ActivityThis nurse-guided, patient-centered approach combines ongoing peer support from a trained elder with home visits and followup phone calls from an advanced practice nurse (APN) for elderly, unpartnered individuals who are discharged from the hospital after a heart attack or bypass surgery. The program is intended to encourage compliance with medication regimens and recommended lifestyle changes, with the goal of reducing hospital readmissions. Key elements of the program are described below:
- Patient enrollment: Eligible patients are over 65 years of age, unpartnered (single, divorced, widowed), able to speak and read English, and have access to a telephone. Eligible patients are identified, provided information, and asked to participate in the program by the hospital nurses.
- Recruitment and training of peer advisers: Two master's-prepared APNs with expertise in cardiovascular nursing recruit and train peer advisers from cardiac rehabilitation programs. Peer advisers are more than 60 years old with a history of heart attack or CABG surgery, with the average adviser having had the acute event 4 years before participating in the program. All peer advisers have also successfully completed a cardiac rehabilitation program and are actively following a healthy lifestyle. During the clinical trial, APNs trained 45 peer advisers, 24 of whom remained active during the entire project. Advisers dropped out for a variety of reasons, such as personal or family health, lack of interest, work commitments, relocation, and death.
- APN outreach: APNs visit the home of each participant within 72 hours of hospital discharge and make followup phone calls at 2, 6, and 10 weeks postdischarge. The APNs reinterpret and discuss symptoms, promote exercise and energy management, and teach about the cardiac disease process.
- Peer adviser outreach: The APN matches the trained peer advisers with a group of post-CABG or post–myocardial infarction patients, with attempts made to provide peers of a similar gender and age and to find a good personality match between peer and patient. The peer adviser calls each participant once a week for 12 weeks. During the calls, the adviser provides verbal encouragement and support, actively listens, and shares lessons and insights from their own experiences. Peer advisers are trained not to give medical advice and to contact the APN if they notice any warning signs during the call that warrant followup.
Context of the InnovationSubjects in this study were admitted to the cardiac services of five academic medical centers on the east west coasts of the United States. The developers launched this program in an effort to support older adults, particularly older female adults, in caring for themselves after discharge from the hospital following a heart attack or bypass surgery. The impetus for this study was that it builds on prior work in which peer advisers and APNs were used to provide social support and teach self-efficacy techniques to this population.
ResultsA 247-patient randomized controlled trial (RCT) at five university medical centers found that the combination of nurse and peer adviser outreach improved adherence to medical recommendations and reduced hospitalizations due to cardiac-related complications, but failed to reduce overall hospital readmissions.
Strong: The evidence consists of a 247-participant RCT evaluating the program's impact on adherence to medical recommendations and readmissions.
- Better adherence to medical recommendations: Program participants were significantly more likely to adhere to medical recommendations at the 1-year point after the cardiac event than were members of the control groups (there were four patient groups—a separate intervention and control group for post-myocardial infarction patients and for post-CABG patients). There were significantly more participants in cardiac rehabilitation programs after 3 months (34 vs. 16 subjects in usual care). This increase was seen up to 1 year after heart attack or bypass surgery. The adherence to a healthy lifestyle was higher in program participants at 1 year, with program participants scoring 75 versus 70 in the usual care group on a scale from 0 to 100.
- Reduced hospitalizations due to cardiac complications: Program participants had fewer hospitalizations for cardiac-related complications during the 6-month period after the program ended. From 3 to 6 months after heart attack or bypass surgery, there were only two readmissions in program participants, while there were nine readmissions in the usual care group.
- No difference in overall readmissions: There were no statistically significant differences between the control and experimental groups for overall readmissions to the hospital, although when the data were pooled, there were more readmissions in the heart attack group than the bypass surgery group. Each of these participants had additional two to three comorbid conditions that may have added to their illness burden. These comorbid conditions may have been exacerbated by the heart attack or bypass surgery, leading to readmissions to the hospital.
Planning and Development Process
- The main planning and development step was providing training to the peer advisers: The APNs led a 1-day session that focused on role playing and reviewing criteria for when to notify the APN with concerns.
Resources Used and Skills Needed
- Staffing: Program staff consisted of two APNs and 45 peer advisers.
- Costs: Each APN was a 0.5 full-time equivalent, so the intervention for 121 participants was one full-time APN for 4 years. This included the time the APN-provided support to the peer advisers. The primary costs consisted of compensation to the two APNs and payments to peer advisers, which were $100 per subject for their work over the 12-week period (most peer advisers donated these payments to the American Heart Association).
Funding SourcesThe program was funded by a grant from the National Institute of Nursing Research (RO1-NR05025) Improving Health Outcomes for Cardiac Elders program, which covered compensation to the two APNs.
Getting Started with This Innovation
- Funding: Look to secure outside funding because the services of the APNs and peer advisers are not generally covered by insurance.
- Recruitment: Expect peer adviser recruitment to be a time-consuming, ongoing process.
Sustaining This Innovation
- Administrative support: Ensure that adequate administrative support exists for the project. This includes an understanding that peer advisers require support to effectively perform their role. In this study, the APN not only supported the program participants, they also spent time supporting the advisers, who never remembered being as sick as the program participant.
- Peer adviser role: Acknowledge and recognize the unique perspective and role of the peer advisers; maintaining their interest in the program is critical to ongoing success.
Additional ConsiderationsPairing a peer adviser with an unpartnered, elderly cardiac patient can create a "win-win" situation in which both individuals gain friendship and emotional support. This low-cost strategy can be effective in improving health outcomes.
Contact the InnovatorDiane L. Carroll, PhD, CNS, APRN, BC, FAAN
Yvonne L. Munn Nurse Researcher
Yvonne L. Munn Center for Nursing Research Institute for Patient Care
Massachusetts General Hospital Chair
Panel B, Human Research Committee Partners HealthCare System
Phone: (617) 724-4934
Innovator DisclosuresDr. Carroll has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesCarroll DL, Rankin SH, Cooper BA. The effects of a collaborative peer advisor/advanced practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. J Cardiovasc Nurs. 2007;22(4):313-9. [PubMed]
Carroll DL, Rankin SH. Collaborative intervention improves adherence in cardiac elders. Clin Nurse Spec. 2008;21(2):104. [Conference Abstracts, 2007 NACNS National Conference: February 28-March 3, 2007, Phoenix, AZ.]
Hiltunen EF, Winder PA, Rait MA, et al. Implementation of efficacy enhancement nursing interventions with cardiac elders. Rehab Nurs. 2005;30(6):221-9. [PubMed]
Winder PA, Hiltunen EF, Sethares KA, et al. Partnerships in mending hearts: nurse and peer intervention for recovering cardiac elders. J Cardiovasc Nurs. 2004;19(3):184-91. [PubMed]
Carroll DL, Rankin SH, Cooper BA. The effects of a collaborative peer advisor/advanced practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event. J Cardiovasc Nurs 2007;22(4):313-9. [PubMed]
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Original publication: July 21, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 02, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.