Richard P., a 54-year-old man with multiple chronic conditions including heart failure, high blood pressure, and diabetes was frequently admitted to the hospital. Following his hospital discharge, his family caregivers were overwhelmed with his care at home. They didn’t understand how to care for his multiple medical conditions. His life seemed like a revolving door from the hospital to home and back again to the hospital. Then, when his physician suggested home health care, Richard formed a new lease on life.

Heart failure is the leading cause of hospitalization for older adults. According to the Centers for Disease Control and Prevention (CDC), patients with heart failure are responsible for 12 to 15 million physician office visits and 6.5 million hospital days a year. In addition, a study by the New England Journal of Medicine (NEJM) found that 20 percent of fee-for-service Medicare patients are readmitted to the hospital within 30 days of discharge, and 34 percent go back into the hospital within 90 days.

“It is important that people with heart failure understand and manage their condition on a daily basis to prevent it from worsening,” said Elizabeth Kleber, RN, MSN, manager of clinical leadership at BAYADA Home Health Care. “Otherwise, they are at risk for serious health consequences and recurring hospitalizations.”

According to Kleber, home health care services can help patients who are experiencing heart failure-related symptoms or complications, including:

  • A recent exacerbation that required a hospitalization or emergency room visit
  • Shortness of breath
  • Persistent cough or wheezing
  • Multiple medication management with a recent medication change
  • Lack of appetite or constant nausea
  • Recent fluid build-up
  • Recent falls due to medication side effects or fatigue

BAYADA teaches patients to recognize when symptoms are occurring and when they may need intervention. By asking themselves some simple questions every day ("What do I weigh?" or "Have I been more tired than usual?"), people with heart failure can take the necessary actions to help avoid a hospitalization and remain safely at home.

Home health care for heart failure and other chronic conditions is a preferred and less costly option to hospitalization. Most people want to remain at home where they are more comfortable and there is less risk of acquiring a hospital-borne infection. In addition, for those patients who require intermittent assistance to manage their conditions, home health care has been shown to improve patient outcomes, including functional status.

In-home services for patients with heart failure can include nursing, therapy, and assistive (personal) care, as well as patient education to learn how to manage their condition safely at home.

After a November 2010 hospitalization, Richard received nursing and therapy from BAYADA for a few months. BAYADA clinicians followed up with him daily and used teaching tools developed by the company’s heart failure experts to educate him on the warning signs that his condition may be worsening and are becoming life-threatening. If certain warning signs occurred, Richard was taught to know when to contact his BAYADA clinician—who could use targeted interventions in order to avoid an unnecessary hospitalization—or when to go directly to the ER. He also learned how his medications helped his various conditions and understood why it was important to take them as directed by his physician.

The NEJM study authors noted that “Rehospitalizations could be avoided with a better planned and executed discharge planning process, greater follow-up, monitoring of chronic illnesses, and connecting discharged patients to doctors.” Richard’s nurses and therapists from BAYADA coordinated with his hospital discharge planner, followed up with him after discharge, continuously monitored his chronic illnesses, and acted as a liaison between him and his primary care physician.

When Richard was discharged from BAYADA, he was feeling empowered and in control of his condition. A few months later, when his ankles began to swell and he gained a few pounds overnight, he knew what he needed to do. Recognizing this as a serious complication of heart failure, he went directly to the ER and was then admitted to the hospital until he was stabilized. Had he not recognized the symptoms and the need to go immediately to the hospital thanks to the education from BAYADA, his condition could have become life-threatening.

Today, Richard is doing well and remains in control of his health. He says he feels more than 100 percent better than he did before being cared for by BAYADA.

Learn more about how home health care can help manage a variety of conditions.

Home Care Services at BAYADA


Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med; 360:1418-1428, April 2, 2009.
Chen, Kane & Finch (2000); Kane, Chen, Finch, Blewett, Burns & Moskowitz (2000); Anderson, Pena & Helms (2001).