The intervention included intensive education
by a study nurse about the consequences of heart
failure in daily life by use of a standard nursing care
plan developed by the researchers for older
patients with heart failure.Important topics were
discussed with every patient (eg, recognition of
warning symptoms of worsening heart failure, sodium
restriction, fluid balance, and compliance). In
addition, problems experienced individually were
discussed (eg, problems in social interaction, sexual
function, and limited access to the general practitioner).
Most patients received an average of 4
visits in the hospital, 1 telephone call, and 1 home
visit. During admission to the hospital, the study
nurse assessed the patients’ educational and counseling
needs, provided education and support for
the patient (and family), gave the patient a card with warning symptoms, and discussed issues
related to discharge. Within 1 week after discharge,
the study nurse called the patient at home to
assess potential problems and to make an appointment
for a home visit. During the home visit the
study nurse reinforced and continued education as
warranted by the patient situation. If needed, the
home care nurse was informed in writing about
specific patient needs. Between hospital discharge
and the home visit, patients could call the study
nurse if they encountered problems. After the
home visit, the patients were advised to call their
cardiologist, general practitioner, or emergency
heart center about any problems