What Matters Most? Qualitative Findings from the Home Health Heart Failure Nurse Navigator Study

HF is the most common reason for hospital admission and readmission of older adults and those readmitted within 30 days have a higher mortality rate at 6 months. The transition from hospital to community has been identified as a vulnerable time when patients must assume responsibility for their own care. No one strategy has been found to reduce 30-day readmissions or 6-month mortality rates. The Heart Failure Nurse Navigator (HFNN) is a home health registered nurse with specialized training in HF care. In this IRB-approved study, an HFNN visited intervention group participants once in the hospital, followed by weekly home visits for 1 month. Control group participants received usual care, with discharge teaching by nursing and follow-up with their provider. The qualitative research question was "What are the perceptions of older adults (≥65) with a diagnosis of HF who transition from hospital to home regarding care received from a Heart Failure Nurse Navigator?" Qualitative data were transcribed verbatim, then key thoughts and concepts were identified and organized into similar categories. Two main categories emerged: Personal Clarification of Patient Education, especially related to diet, exercise, and medications, and Feelings of Support, Reassurance, and Safety. Meeting the HFNN in the hospital was the beginning of the caring relationship that continued through the home visits. As the caring relationship developed, the HFNN, patient, and family determined together what mattered most during this crucial transition. Providing specialized HF instruction to home health nurses may give them a stronger base from which to offer comprehensive education, support, and reassurance to patients with HF.