Group Classes Help Inpatients Take Heart from Each Other

Patients with heart failure need to be “on their game” all the time to stay out of the hospital. That’s how Theresa Cary, MSN, RN, ACNS-BC, CHFN, CCRN, describes the challenge facing patients she cares for as the clinical nurse specialist for the medical cardiology unit on Cleveland Clinic’s main campus.

This is the thinking behind the multidisciplinary Heart Failure Survival Skills Class that Cary manages and helped develop. Since launching the in-hospital class in January 2012, Cary and her team have educated more than 3,000 hospitalized patients with heart failure and their family caregivers. The class has recently expanded to five days a week, with participants receiving information and practical tips to stay healthy and avoid readmission.

A three-pronged multidisciplinary approach

The one-hour class is broken into three 20-minute segments — on medication management, dietary guidance and survival skills — taught by a pharmacist, a dietitian and a clinical nurse specialist.

The pharmacist covers why heart failure medications are important, which meds improve survival, which meds make patients feel better and why it’s vital that patients take their meds as instructed. The dietitian then explains why a low-sodium diet is important and — critically — provides practical advice on how to maintain the right diet, including websites and resources on how to eat well, even at restaurants. The clinical nurse specialist leads the survival skills segment, which links recommendations for heart failure self-management to the preceding medication and dietary instructions.

“The survival skills portion weaves together the medication and dietary portions and helps patients apply them practically so they better understand the reasons for postdischarge management recommendations,” says Cary, who usually teaches this portion. “For example, to explain why our Heart Failure Zones handout tells patients to weigh themselves every day and compare that weight to their dry weight, I refer back to the pharmacist’s definition of heart failure and re-emphasize the impact of dietary sodium and heart failure medications on weight.”

The class is offered three times a week in a conference room on Cary’s unit. Class size varies, but six to 10 participants seems to be ideal, she says.

An adjunct to one-on-one teaching

Cary emphasizes that the group classes are meant to complement, not replace, one-on-one education that nurses continue to offer patients.

“My portion of the class mirrors some of what nurses are teaching individual patients at the bedside,” she says. What’s different is that the multidisciplinary format allows Cary to better integrate instructions with the reasons behind medication and dietary recommendations, and to translate self-care expectations into practical advice. “It’s an opportunity to bring all the pieces together to help patients make sense of the overall picture and come away with tips on how to survive.”

Strength in numbers

Patients tell Cary the group format adds a vital element as well. “Heart failure is a very difficult condition to deal with, so it’s encouraging for patients to be around others with heart failure and know they’re not alone,” she says. “There are usually a few class participants who are upbeat. Their advice and encouragement is contagious for others who have struggled to manage their heart failure.”

She adds that fellow patients and family members can offer support in ways she never could because she’s not walking in their shoes. “When a fellow patient says, ‘There are so many tasty and healthy recipes out there — let me share some with you,’ it’s a completely different message than if it comes from me,” Cary explains. She and her pharmacist and dietitian colleagues invite that kind of interaction by actively encouraging questions and dialogue throughout the class.

A singular offering

Although group classes for patients are common in outpatient settings, they are far less common in the inpatient setting, and the multidisciplinary aspect of Cary’s group class further distinguishes it.

The class’ multidisciplinary nature was a key to its genesis, as the idea for it had been simmering between Cary and a dietitian colleague, Renee Welsh, MS, RD, LD, for months when Cary was approached in late 2011 by a pharmacist colleague, Jodie Fink, PharmD.

In June 2011, the Department of Pharmacy had begun providing one-on-one medication management instruction to Medicare patients with heart failure. Fink soon realized that a group format would allow more patients — including non-Medicare patients — to benefit from this education, so she suggested the concept to Cary. That suggestion was the spark that activated Cary and Welsh’s idea, and the team began presenting trial runs of the class to nurses on Cary’s unit within weeks.

In addition to garnering nurses’ support for the class, the trial runs yielded valuable input from nurses for refining content of the class.

Cary says the 30-day all-cause readmission rate for patients with heart failure who completed the class during its first 10 months was 6.9 percent, but no formal comparative analysis with the rate for patients not completing the class has been performed yet.

“If nothing else, the class impacts patient satisfaction,” Cary notes. “Most patients leave the class smiling and excited about what they’ve learned. It’s fun to watch their eyes light up when some explanation or example helps them truly understand a concept they didn’t quite get before. That happens often.”

Inpatient group instruction for other conditions: The Case of Lung Transplant

Nurse-led group classes for inpatients with chronic health issues are catching on at Cleveland Clinic for conditions beyond heart failure. The concept took hold recently — albeit without the multidisciplinary twist — to improve education in self-management by patients following lung transplant.

The post-transplant self-management classes are the brainchild of Maria Lamenza, BSN, RN, who teaches the classes, and Marie Budev, DO, medical director of Cleveland Clinic’s lung transplant program, which performs more than 100 transplants a year.

“At least 70 percent of the success of a lung transplant depends on effective patient education in medication and lifestyle compliance,” says Lamenza, who is the post-transplant coordinator for Cleveland Clinic’s lung transplant unit.

Yet Lamenza was finding that patients often were not awake or alert enough when she would educate them in their rooms. Her suspicions were confirmed when she heard from the outpatient post-transplant coordinators that many patients were coming to them with little retention of what they had been taught in the hospital.

That’s when Lamenza and Dr. Budev decided to supplement the patients’ one-on-one education by “getting patients up and getting them in a room together” for group instruction, Lamenza says. She launched her group classes in June 2012.

Now, classes are held on the nursing unit every week in two sessions — two hours (sometimes longer) on Tuesdays and one hour on Thursdays. Tuesday sessions cover information about the post-transplant clinic and outpatient appointments as well as bronchoscopies, graft rejection issues, diet and lifestyle changes, special equipment needed, monitoring tests and similar issues. Thursday sessions are devoted to medications — from anti-rejection meds to anti-infectives — and cover side effects, interactions and the imperative for adherence.

After instructing more than 70 patients in group classes, Lamenza saw many benefits reported by Theresa Cary in her heart failure group classes. “Patients really interact and learn from each other,” Lamenza says. “We get very good feedback from patients — they enjoy getting out of their room and talking with others in the same situation.” And the outpatient post-transplant coordinators report that patients now come to their clinic knowing more about their medications and post-transplant issues in general.

Classes can be especially helpful for family members, who often attend when their loved one is still intubated and sedated in the intensive care unit. “Being able to see other patients recovering — including a volunteer who attends most classes and is thriving five years after his own lung transplant — gives them hope,” Lamenza says.

Lamenza plans to start formally measuring the classes’ impact on patient outcomes, but she’s already convinced the classes are worthwhile. “Group instruction helps with retention of information, and that’s critical for these patients.”