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caring, heart failure, older adults, quality, telehealth, theory-guided interventions



  1. Duffy, Joanne R. PhD, RN, FAAN
  2. Hoskins, Lois M. PhD, RN, FAAN
  3. Dudley-Brown, Sharon PhD, FNP-BC


Newly discharged older adults with heart failure continue to experience frequent hospital readmissions, lower quality of life, and decreased satisfaction with health services. A theory-guided intervention delivered by home health nurses via the telephone was studied using a randomized controlled trial to assess its feasibility and inform further studies. Findings generated a profile of older adults with heart failure, utilization by patients and nurses, operational issues, and preliminary data on intended outcomes. Implications for further study are presented.