Result card

  • ORG1: How does structured telephone support (STS) for adult patients with chronic heart failure affect the current work processes?

How does structured telephone support (STS) for adult patients with chronic heart failure affect the current work processes?

Authors: Valentina Prevolnik Rupel, Taja Čokl, Eleftheria Karampli

Internal reviewers: Ulla Saalasti - Koskinen, Elle Kisk, Ricardo Ramos

To answer the questions in the assessment elements we mainly used the basic literature search provided for the whole project. Additionally, two more systematic searches were used: one performed by ORG and ECO domains (described in methodology of ECO domain) and one perfomed by EFF, SAF and ECO domains (described in SAF domain). The results are provided in descriptive way.

STS can be carried out in very different settings, from primary care to tertiary care. There is little information in the studies on the changes of the workflow – usually for the STS an additional nurse was used who had access to patient data, carried out the STS, monitored the patient, recorded the symptoms and data and reinforced and adapted the plan of care for the patient. The other medical professions did not get involved in STS directly, only indirectly, through the STS nurse, who coordinated all the activities and services around the patient. No study specifically recorded the (decrease or increase of) workload for other specialists in case a STS nurse was involved in the work. Staples et al {6} describes how to manage human resources and the division of roles between nurses. During the 2007 calendar year, there were 1.356 patients visits to the HF clinic and telephone calls accounted for an additional 1914 patient encounters in 2007. One full-time nurse practitioner, one clinical nurse specialist (working 0,7 of a full-time equivalent), and one registered nurse (vacation replacement) provided the nursing interventions with the telephone visits. Nurses spent 24 % of their working hours doing 1.914 telephone calls in one year. As most of the studies are conducted in controlled academic environment or non realistic setting, it might be that additional option should be considered in real setting, like hiring a nurse, use of low cost telephone service, use more time for outcomes dissemination and results discussion in a team.

Standard care of HF patients discharged from an acute care setting, may include patients’ follow-up visits to a PCP, participation in a CHF management programme run by a health care provider (for example a clinic), or visits at the patient’s home by specialised CHF health professionals. According to one point of view, telehealth can substitute home visits by healthcare professionals or visits by the patient to physicians’ offices and clinics {9}, therefore the provision of STS programmes and RM in general can be considered a ”reengineering of health care processes” {40}. According to another point of view, RM is rather a different way of systematically organizing effective care and should not be seen as replacement for specialist care or multidisciplinary heart failure clinics {1280}. The heart of the medical practice is the relationship between a care provider (physician, well-trained nurse, etc.) and a patient in focus. New technologies should be viewed as potentially useful adjuncts in selective subgroups and using specific parameters to be defined in good RCTs. They should not be the centrepiece of redesigned health care system on top of UC- technology comes second and the patient-centered relationship between patient and provider comes first {80}.

The STS programs described in the literature present variations. In terms of the various actors involved in the process, all interventions are performed by nurses who have access to patient records, and through the STS intervention can monitor the patient, record symptoms, reinforces the treatment plan and makes adaptations to medications or can refer  patients to other healthcare professionals e.g. dietician.

Other healthcare professionals may also be involved in the STS program through various procedures. They can be involved in the development of the STS intervention. Also, during the provision of STS, physicians and pharmacists can be involved via regular monitoring of reports sent by the nurses, supervising of the STS intervention, providing instructions and feedback to the nurses regarding the treatment plan or training nurses on problems that were encountered during the telephone communications with the patients. Healthcare professionals such as nurses, physicians, pharmacists, social workers, dietitians, cardiac rehab specialists and other health care professionals may also be involved in providing patient education before discharge from the hospital.

In STS programs, patients and their family/carers have a more active role as they receive education regarding their illness, symptoms and treatment, and are required to self-monitor and report to the HF nurses, thus constituting important actors in the procedure.

Other actors that were reported in some of the studies include technical staff (when the intervention included videophone); health plans’ case managers who communicated with nurses carrying out the STS program and provided information on issues relating to the plan benefits such as durable medical equipment procurement and transportation difficulties; and, the telemedicine providers who offer consulting services that include program support as well as healthcare personnel and patient training to organizations that are implementing or plan to implement STS programs.

In case STS is an add on to same work process and no changes in work process are visible, additional work for nurses as well as physicians is necessary. In most studies, additional nurse (called centralized nurse{230}, registered nurse {230}, nurse case-managers {230}, cardiac nurse {230}, study nurse {1}, HF nurse {200} ) specially trained in management of HF, led the STS, monitored patients’ status and advised patients.

In the Tele-HF trial the reports were reviewed regularly by physicians and medications were adjusted as necessary {1150}. In another case, the standard care work process after discharge was as follows {1}: medical center staff provided all subjects the usual discharge teaching, also follow up clinic appointments were scheduled in the usual manner for all subjects. UC subjects contacted their primary nurse case manager by telephone if needed. Intervention subjects, on the other hand, contacted their assigned study nurse if needed. Two additional registered nurses conducted all intervention contacts for intervention patients – they reviewed the discharge plan during the first intervention contact and reinforced it during subsequent contacts. When subjects reported symptoms, nurses reviewed the data, reinforced the plan of care and made referrals (eg. dietitian) or contacted physician for care plan adjustment. Study nurses had full access to the subject’s medical records through the Computerized patient record system. When STS included videophone, more technical staff needed to be involved due to the fact that 76% of encounters were limited by technical problems, primarily poor video resolution {1}.

In a randomized, controlled clinical trial conducted in the U.S. {2} disease managers were employed by CorSolutions, Inc, which is an established DM company and was contracted for the study. A challenge that arised in such a setting was that physician did not welcome input from disease managers. A small number of potential patients for the trial withdrew from considering participation after they were advised by their physicians they should not enroll, some of whom stated they would no longer see the patient if the patient participated in DM.


In the German HeartNetCare-HF Würzburg study, the heart failure nurse {200} was set in a centre of services provision for the patient. Her working environment was in a hospital and she used a hospital telephone line to carry out STS. Soon a special relationship was established between a nurse and a patient. One nurse could support 100 to 120 patients. She worked under the supervision of cardiologist as well as psychologist. As a nurse could do some work which was done by cardiologist earlier on, the doctors had less workload. However, a special knowledge and additional training is necessary before such nurse can take on additional responsibilities.


In another study {1500} nurses trained in the management of patients with HF based in a centralized calling center contacted intervention patients. Answers to questions were collected using software and analyzed by the system to identify at-risk patients. Nurses contacted a patients’ cardiologist as needed during the interventions.

There is a lack of published data about the nature of nursing interventions that are required to provide telephone management for patients with HF. Staples et al describes how to manage human resources and the division of roles between nurses. During the 2007 calendar year, there were 1.356 patients visits to the HF clinic. Telephone calls accounted for an additional 1.914 patient encounters in 2007. One full-time nurse practitioner, one clinical nurse specialist (working 0,7 of a full-time equivalent), and one registered nurse (vacation replacement) provided the nursing interventions with the telephone visits. Nurses spent 24 % of their working hours doing 1914 telephone calls in one year. Nurses initiated 65 % of calls; others were received from patients, family members and other health care providers. When patients called about troubling symptoms (other than HF), non-HF issues, or seeking information on other topics, interventions were required that only the nurse practitioner could provide. The nurse practitioner was usually the only nurse who could make medication changes based on diagnostic test results {6}.


A consistent nurse case manager who cares for the patient and connects family, tries to understand goals and specific outcomes, provides information and monitors patient, can help other members of health team understand the patient and coordinates services. Since most of the studies are completed in academic settings or a specific study setting is created, the clear influence of the implementation of intervention might exist in community based agencies. For example, health care centers in real setting may consider low cost option of nurse run telephone care services or improving fragmented care by employing nurse case manager. There is more time needed for routine dissemination of outcomes data and discussing results with staff {240}.


The work processes due to telehealth might be affected also on the side of the patients. For example, if a patient needs a telephone line to perform STS while at work, his or her workpalce might lack the facilities, privacy and comfort needed. Public, residential and commercial spaces might need to be redesigned to include health kiosks or other appropriate spacesfor STS. Also, providers might need different environment or office to perform STS {3}.


Where primary care services are well developed, the GP and community nurse could be involved in the routine monitoring of the stable patient, although the evidence for this is not secure. UC/STS should be incorporated into the activities of the multidisciplinary team, with timely communication between primary, secondary and tertiary care being vital. This is often not the case {100}. Once a patient is on optimized medication, the PCP and community HF nurse can continue to monitor the majority of patients. 

Rupel V et al. Result Card ORG1 In: Rupel V et al. Organisational aspects In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 2 December 2022]. Available from: