Given the multitude of public health and policy implications associated with hospital readmissions (1, 2), considerable attention has been paid to developing strategies that keep patients from returning to the hospital. Heart failure (HF) patients, a chronically ill population whose prevalence is increasing (3), are frequently readmitted to the hospital. The national 30-day readmission rate for Medicare patients admitted for HF in 2010 was 24.6% (4), essentially unchanged from the previous two years, and among all Medicare patients those with HF are more likely than any other patient group to be readmitted (2). There has been considerable effort to lower this readmission rate as part of broader health care reform, and Medicare has begun to inflict financial penalties on hospitals that have excessive readmission rates (1).
Because HF readmissions are common, multiple approaches have been considered to reduce them. Some hospitals have used education classes (5) while others have piloted programs that involve having nurses follow patients in their homes (6). One national initiative that was begun in 2002 is the Joint Commission’s (JCO) standard for discharge instructions (7, 8). This standard, known as HF-1, requires that all discharge instructions address 6 specific areas related to HF management: activity level, diet, discharge medications, follow-up appointments, weight monitoring, and procedures to follow if symptoms worsen (7). Although this standard was developed based solely on expert opinion, previous research has shown that among 782 HF patients, those who received instructions that adhered to these JCO guidelines were less likely to be readmitted within one year of discharge than those who did not (9). This study, though suggestive of the importance of HF-1, was limited by its retrospective nature and focus on 1-year readmissions as a primary outcome, which is a distal endpoint for assessing the efficacy of discharge instructions. Additionally, there was no attempt made to determine if patients understood the instructions they were provided. Although ensuring that all patients receive quality instructions is an appropriate initial step, doing so offers little help if they do not understand these instructions. Indeed, multiple studies (5, 10, 11) have shown the importance of education, symptom understanding, and self-care in promoting medication adherence, reducing care costs, and preventing readmissions among HF patients.