Patients With Heart Failure More Likely to Get Readmitted to the Hospital

by Anquinette Cray and Ron Billano Ordona

The at-risk population is the older adult 65 years and older, homebound, with congestive heart failure (CHF).

Patients with heart failure are five times more likely to get readmitted.

They are at greater risk for emergency department (ED) visits or hospital admissions and readmissions. According to our quality improvement project results (Ordona, 2018), homebound seniors with CHF are five times more likely to be readmitted to the ED/hospital.

This is associated with greater use of health resources, morbidity, and mortality (Yang, Ornstein, & Reckrey, 2016). The Centers for Disease Control and Prevention (2016) estimated there are six million adults in the United States with heart failure. The national healthcare cost is approximately over $3 billion. CHF also diminishes the quality of life by 80% for individuals over the age of 65 (Punchik et al., 2017).

The aggregated statistical data of the risk factors, according to the American Heart Association (AHA, 2017), states that in 2010 the estimated cost of heart disease was $863 billion globally and is expected to rise to $1 trillion.

Linking these individuals to needed resources such as education, planning, social support, and community resources can improve this population group’s quality of life. Cardiovascular disease and its risk factors affect patient independence.

According to the AHA, coronary heart disease results in 45.1% of deaths in the United States, followed by stroke 16%, heart failure 8%, and hypertension 9%.

The vulnerable population may have a lack of instrumental support, neighborhood, and community resources. Multiple chronic conditions associated with coping, diminished social support, and a sense of loss of control increase the stress of life.

Transitions into the community is important. Care Home By RNs partners with Senior Care Clinic House Calls to help prevent unnecessary trips to the ER.

Note: Ms. Anquinette Cray, MSN, NP-C is working on her Doctor of Nursing Practice (DNP) project with Grand Canyon University, an offshoot from Dr. Ordona’s previous work on transitional care medical house calls for homebound seniors. Ms. Cray aims to measure perception of home health nurses in caring for homebound seniors during transitions of care in collaboration with the nurse practitioner implementing transitional care medical house call visits.

Dr. Ron Billano Ordona, DNP, FNP-BC is the Gerontological Advanced Practice Nurses Association (GAPNA) Housecalls Special Interest Group (SIG) chair. The SIG meets remotely via telephone/videoconference every first Thursday of the month at 5:30 p.m. (Pacific).

Read more on GAPNA website.


  • Allen, J., Hutchinson, A.M., Brown, R., & Livingston, P.M. (2018). User experience and care for people transitioning from hospital to home: patients’ and carers’ perspectives. Health Expectation, 21(2), 518-527. doi:10.1111%2Fhex.12646.
  • American Heart Association (AHA). (2017). Heart disease and stroke statistics 2017 at-a-glance. Retrieved from…
  • Centers for Disease Control and Prevention. (2016). Interactive atlas of heart disease and stroke. Retrieved from
  • Meleis, A.I. (2010). Transitions theory: Middle range and situation specific theories in research and practice. New York, NY: Springer Publishing Company.
  • Ordona, R. B. (2018). Transitional care medical house call: A pilot project. Boise State University Repository. Retrieved from
  • Punchik, B., Komarov, R., Gavrikov, D., Semenov, A., Freud, T., Kagan, E, Goldberg, Y., & Press, Y. (2017). Can home care for homebound patients with chronic heart failure reduce hospitalizations and cost? PLoS ONE, 12(7). doi:10.1371/journal.pone.0182148
  • Yang, N., Ornstein, K., & Reckrey, J.M. (2016). Association between symptom burden and time to hospitalization, nursing home placement, and death among the chronically ill urban homebound. Journal of Pain Symptom Management, 52(1), 73-80. doi: 10.1016/j.jpainsymman.2016.01.006

Celebrating 2019 with Care Home By RNs Staff

“Collaboration is a key part of the success of any organization, executed through a clearly defined vision and mission and based on transparency and constant communication (Dinesh Paliwal).”

Care Home By RNs staff take time out to celebrate each other.

We beam with pride in having staff who’s been working with us for 6 years or more, as well as new ones who infuse new energy to our organization. Some of our staff has moved on to become RNs, LVNs, Radiology Tech and others. Some are currently in school for professional degrees. We are blessed to be in collaboration with such talents. We look forward to continued mutually productive year 2019!

Thanks to the leadership of Yas Patawaran, operations manager, who handles the day-to-day hustle and bustle, in partnership with team leaders Christina, Manny and Daniel.

We also acknowledge Albert Wilson for being the group’s frontrunner for families and community partners.

Thank you everyone for 2018 and here’s to another mutually productive year 2019!

Polypharmacy and the Readmission Quagmire

Our homebound seniors belong to a growing population group that is vulnerable including unnecessary trips to the ER or hospital. When we implemented a quality improvement project looking into homebound seniors discharged from skilled nursing facilities, we found that more than. half of these seniors come home with 11 medications (the systematic definition of polypharmacy is 5 or more active medications).


By doing transitional care medical house call visit, we were able to significantly reduce polypharmacy to 7 medications. Polypharmacy is one of the quicksands in preventing readmissions to the ER or hospital.

Dementia and the Brain

The portion of the brain that gets preserved, according to Mary Cochran Abraham, GNP, in her presentation to the California Association of Long Term Care Medicine (CALTCM) this fall, includes the areas that control automatic speech and rhythm (circled in blue above). This explains why music can be an integral part of a dementia patient’s comprehensive care plan. It also explains why some of our dementia patients repeat words such as, “help me, help me, help me,” or repeats expletives over and over. 

Emergency Preparedness in RCFEs

AB 3098 is effective January 1, 2019

We cannot stop natural disasters but we can arm ourselves with knowledge: so many lives wouldn’t have to be lost if there was enough disaster preparedness (Nemcova).

AB 3098 was recently signed by Governor Brown, effective January 1, 2019. This bill requires all RCFEs to have additional elements within the emergency and disaster plan. 

… Care Home By RNs has geared up to meet this requirement.

A Picture is worth a Thousand Words

Conducting a fire drill at Aspen Meadows Care Home By RNs in Lincoln, Ca headed by Christina (house manager) and assisted by Mary Ann.

This bill requires all RCFEs to have additional elements within the emergency and disaster plan. In addition, this bill requires Community Care Licensing to confirm, during annual visits, that the emergency and disaster plan is on file at the facility, with required content. Violation of these provisions would be a crime.

Disasters in 2017

The year 2017 was a record year for disasters. Preparation is key, according to the Senior Community Learning.

More information about disaster preparedness can also be found in including disaster toolkits.

Look deep into nature, and then we will understand everything better… (Albert Einstein)

Care Home By RNs

Founded by nurses since 2006

Learn more about us

We welcome comments!


Caring in extraordinary circumstances

by Albert Wilson, RCFE Administrator (excerpts from a letter to state licensing)

As most of us probably notice, the hospitals of today are looking more like ICUs and so consequently the skilled nursing facilities (SNFs) are looking more like the hospital of years ago. Consequently, the Assisted Living Facilities including those of us who are in the 6-bed healthcare space are also seeing this change in the types of clients that are being referred to us.

PEG tube may be a way to continue nutrition when a person is unable to eat by mouth.

For example, we had three separate requests for PEG tube care in the last week alone. We let the families and discharge planners know we will work on developing a strategic care plan that will help address these needs. As we know, some of these PEG tube clients either do not have enough funding to afford SNF care at private pay or just are not able to thrive in a large-scale care environment that a focused care environment (that small homes) can provide may benefit them.

A reducted approval letter for PEG tube care at Care Home By RNs facility.  CONFIDENTIAL: Pls do not copy, print or distribute.

To worsen matters, some of our seniors are either clogged up in the hospital ERs or SNFs that worsen the hospital/ER readmissions problem. 

At Care Home By RNs, we are hoping that we would be able to meet licensing requirements and regulations (through exceptions) to take care of clients with PEG tubes in a small home-like environment. It’s been rightly told to us that regulations show PEG tubes are outside the scope of RCFE’s.

Care Home By RNs is continuously working on innovations in the care for seniors in the 6-bed residential care realm. A program/action plan in collaboration with a medical house call practice who can provide the medical and nursing oversight may be able to make the care in this extraordinary circumstance be a reality.

We have had success in getting an exception granted in a Care Home By RNs facility in the Bay Area. We’re open to new ideas on how to move forward now or in the near future to find a way to serve our community and families in need of PEG tube care.

Diabetes management options at Care Home By RNs

by Dr. Ron Billano Ordona, DNP, FNP-BC

According to an article in the American Family Physician, a comprehensive, collaborative approach is necessary for optimal treatment of patients with type 2 diabetes mellitus. Treatment guidelines focus on nutrition, exercise, and pharmacologic therapies to prevent and manage complications.

Nutrition plays an important role in diabetes management.

Care Home By RNs collaborates with the Senior Care Clinic Medical House Calls to provide both nursing and medical oversight to prospective residents needing diabetes care that involves injections. As a general rule (with exceptions), RCFEs are not designed to manage diabetes injections, let alone titrate the medication to a once-a-week treatment modality*, saving the family the expense (or hassle) of 2-3 times daily insulin injections. 

Advances in diabetes management provide options for once-weekly dosing especially for patients living in places of residence that has restrictions to using injectable medications. With careful planning and monitoring, though, a once-weekly dosing is achievable.

*not applicable in this case scenario to type 1 diabetes or Kaiser patients. 

Referenced in this article: Am Fam Physician. 2015 Jul 1;92(1):27-34

Improving Access to Care: APRNs in House Call Practice

by Dr. Ron Billano Ordona, DNP, FNP-BC

For us in the house calls practice, as soon as we see our first elderly, homebound patient of the day, we get the rewarding feeling that these vulnerable seniors would have ended up in the emergency department if not for our preventive care. For this vulnerable population group, APRNs in the house call practice provide the much-needed access to care.

As such, the American Association of Retired Persons (AARP)’s Campaign for Action1 supports changes that would allow APRNs to certify for home health services. Removing this barrier will mean that more Americans will have improved access to high-quality, affordable health care, when and where they need it. This is especially necessary for those who are homebound and vulnerable, as well as those in underserved areas or rural of the country.

APRNs, particularly those that do house calls for homebound seniors, act as a bridge to improving access to care for the growing population of seniors. An increasing number of homebound seniors are not able to see primary care providers in their offices but do need home health services. In some U.S. states, APRN practices have to wait for collaborating physicians’ signature on home health certification documents thereby, delaying the delivery of care.

It would be in the patient’s best interest that the provider who makes the house call to be the provider who certifies the need for home health services and communicates those needs to the Medicare-certified home health agency2.  

We would like to meet with more GAPNA members who do house calls. Please see us at the national conference in Washington, D.C. in September. The Housecalls SIG, which meets via telephone and video conference monthly every first Thursday at 5:30 PM (Pacific), would like to meet and greet September 28 at 4:30 pm (Eastern). Exact room will be announced at the conference. Please watch out for it or reach out in advance.


1 AARP Foundation. (n.d.). Improving access to care. Retrieved Aug 16, 2018, from
2 Brassard, A. (2012). Removing barriers to advanced practice registered nurse care: Home health and hospice services.Insight on the Issues, 1-10. Retrieved Aug 16, 2018, from…)

This article was published on the GAPNA website:

Care Home By RNs

Welcome to Care Home By RNs blog. Nurses are the most trusted professionals. Nurses as entrepreneurs is a concept that we support and nurture. Who would better serve an honored but vulnerable senior population but those who know caregiving from the get-go?

Founded by Nurses since 2006