This proposed study aims to conduct a randomized clinical trial involving elderly patients (age 65 or older) hospitalized at one of four Philadelphia area hospitals with a primary DRG classification of heart failure (DRG 127). A total of 140 patients will be recruited into each of two comparison groups: (a) a control group that will receive routine discharge planning and home care; and, (b) an intervention group that will have a multidisciplinary, comprehensive follow-up care coordinated and implemented by an Advanced Practice Nurse (APN). Subjects will be identified within 24 hours of hospital admission and randomization will occur after patient consent is obtained. For the experimental intervention, the APN will make initial patient contact in hospital within 24 hours of admission in order to establish a trusting relationship and to initiate a comprehensive patient assessment. The APN will make daily hospital visits lasting 30-45 minutes to complete the comprehensive patient assessment and coordinate the multidisciplinary and attending physician discharge follow-up care plan. Within 24 hours following the patient's hospital discharge, the APN will make an initial home visit. Home visits by the APN will be made weekly for the first month and then bimonthly up to three months post-discharge. The APN will also be available daily for telephone consultation at scheduled hours: patients will be instructed to contact their physicians or local hospitals for emergency care at other times. Data collection will be done for both comparison groups during the acute hospitalization, and at 2, 9, 16, 26, and 52 weeks post-discharge. Study variables include both patient outcomes and cost of care outcomes. Patient outcome data will include patient's management of the heart failure, rehospitalizations, acute care giver visits, general health behaviors, physical health and functional status, emotional status (depression), social support, quality of life, and satisfaction with care and social support. Costs of care will be estimated for the index hospitalization, rehospitalizations, acute care visits, post-discharge health care services, and APN services (intervention group).
