Heart failure advocates help patients comply
Heart failure advocates help patients comply
Focus is on self-management, empowerment
Having heart failure advocates work with discharged patients to help them self-manage their care cut the rate of readmissions within 30 days from about 20% to 5%-6% at six hospitals that are part of the Catholic Healthcare Partners health care system.
The project was funded by a grant from the federal Agency for Healthcare Research and Quality (AHRQ), awarded to the five-state health system in 2002.
Although funding for the project ran out in 2006, and the last patient advocate position was eliminated in June 2008, private insurers and other entities have expressed an interest in reviving the initiative, says Margie Namie, RN, MPH, CPHQ, vice president of quality for Mercy Health Partners Southwest Ohio.
"The program was highly effective, but we were not able to continue to support the program when the payment system didn't support it. Payers are looking for solutions to patient noncompliance and rehospitalization. We are hoping to start something like this program again," she says.
AHRQ heart failure program
Catholic Healthcare Partners participated in an AHRQ program to improve care for heart failure patients by promoting consistent use of evidence-based guidelines.
"Because our strategic plan focused on chronic illness and addressing the continuum of care, our goal went further than just meeting the care recommended in the core measures and included reducing unnecessary readmission," Namie says.
When the project began, a multidisciplinary team tracked the readmission rates within 30 days of discharge of patients with heart failure who were readmitted for any reason.
The main cause of readmission was failure to adhere to the plan of care, because of real or imagined barriers — including medication issues — failure to stay on a salt-free diet, and lack of understanding of what to do when symptoms worsen, Namie says.
"We quickly identified that we did not have people on staff who could aid the patient in transitioning from the hospital to home," she adds.
The health system created the heart failure advocate position to assist people after discharge. The advocates were nurses who worked with the patients to help them set goals, to overcome barriers to appropriate management, and to identify early signs of relapse and get appropriate help.
"What made this unique over other case management programs was that the nurses worked toward patient self-management and empowerment. Rather than just calling the patients every few weeks, they helped the patients and caregivers learn to effectively manage on their own. There was a small percentage of patients we were not able to impact, but we could improve compliance of most of them once we assisted them in setting goals," Namie says.
The nurses received clinical education on heart failure through Cleveland's Case Western Reserve University. The health system provided training on how to communicate with patients and physicians and ongoing education and training from advanced practice nurses.
"We gave these nurses the training they needed to assume a nontraditional role," Namie reports.
The nurses managed the care of 30 to 40 patients at a time and followed them for about three months. If a patient was extremely fragile with ongoing barriers to compliance, the nurses worked with them for six months to a year.
"Most of the intense work with these patients was within the first two months," Namie says.
The nurses saw the patients while they still were in the hospital and visited them in their homes and during doctors' visits when appropriate.
"The interventions were effective because the nurses created very individualized care plans for each patient," Namie says.
Many heart failure patients have difficulty interacting with their physicians, particularly when their symptoms exacerbate, she points out.
For instance, if patients start to gain weight and call their physicians' office, they are likely to speak to someone who is not a clinician and get an appointment to see the doctor in two weeks. By that time, they're already back in the hospital, Namie adds.
"The nurses helped the patients figure out what they needed to say to the physician's office in order to get an appointment that day. This empowered the patients to handle the situation on their own later on," she says.
Medication issues, particularly the cost of medication, were another barrier to compliance among the patients in the project.
"Patients with heart failure take multiple medications, and we found that patients who couldn't afford all of them would pick the top five on the medication list and fill those. We don't prioritize medications that way, but some patients think they were listed in order of importance," Namie says.
Upon first visit
When the nurses met with a patient for the first time, they reconciled the patient's list of medications with what was on record with the physician's office and what the patient had been taking before he or she was hospitalized. They made sure the patient was taking the right medications and educated him or her on when to take which medication.
The nurses helped patients who couldn't afford their medication sign up with medication assistance programs. They helped them find a temporary source of medication until the patients were approved for a pharmaceutical program. For instance, patients in the Youngstown, OH, area who couldn't afford their medication were eligible for up to 60 days of medication through St. Elizabeth Health Center.
Compliance with low-salt diet
Difficulty following a low-sodium diet was another barrier to compliance.
Many of the heart failure patients lived alone and depended on canned foods because they are inexpensive and easy to prepare. The health system created standardized heart failure educational materials, written at a fourth-grade level, to give patients ideas on how to follow a low-salt diet. The nurses worked with the patient to help them identify low-salt foods that fit their budgets.
If the patients were reluctant to give up canned foods, the nurses taught them to look for canned food with reduced sodium or to thoroughly rinse the food before cooking.
(For more information, contact: Margie Namie, RN, MPH, CPHQ, Vice President of Quality, Mercy Health Partners Southwest Ohio. E-mail: [email protected].)Having heart failure advocates work with discharged patients to help them self-manage their care cut the rate of readmissions within 30 days from about 20% to 5%-6% at six hospitals that are part of the Catholic Healthcare Partners health care system.
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