Proactive approach results in lower readmission rates
Proactive approach results in lower readmission rates
HF task force focuses on four key initiatives
When the Centers for Medicare & Medicaid Services (CMS) analyzed hospital readmission rates to post them on the Hospital Compare web site, the lowest heart failure readmission rate in the nation was at the Baylor Jack and Jane Hamilton Heart and Vascular Hospital.
That's because Baylor Healthcare has taken a proactive approach to hospital readmissions, establishing systemwide task forces to develop initiatives for reducing heart failure 30-day mortality and readmissions at all hospitals in the system, says Pam Stafford, RN, BSN, CPHQ, health care improvement process consultant for the Baylor Healthcare System with headquarters in Dallas.
"Heart failure patients have the highest readmission rate of any diagnosis. We are concentrating on heart failure first, but the whole model can be translated to chronic disease management," she says.
The Baylor leadership team assembled a heart failure mortality and readmissions task force several years ago. The team started with a 12-item action plan and honed it down to four key items last year, according to Stafford, who took over the heart failure task force in May 2008.
The measures to eliminate heart failure mortality and readmissions as determined by the task force include using a standardized heart failure order set systemwide; improving medication reconciliation; improving continuity of care from inpatient to the post-acute setting; and focusing on end-of-life or palliative care and advance directives.
"Research does not show that one individual aspect of care keeps patients from being readmitted. We must pay attention to the entire continuum of care to improve the chronic care model. There are a multitude of appropriate interventions, so careful coordination is the key in caring for patients with chronic illness," Stafford says.
Systemwide order set
The Baylor health system instituted a system-wide order set for heart failure in December 2007. The order set includes evidence-based standards of care for heart failure, interventions from the Institute for Healthcare Improvement's 5 Million Lives campaign, and heart failure core measures.
The health care improvement department tracks the usage of the order sets and provides data every month to show outcomes related to when the order set is used vs. when it's not used.
"Our goal is to use the order set 80% system-wide. We're now in the 70th percentile on a monthly basis. We are nearing that goal," Stafford says.
"The use of facility-specific and system physician champions in the heart failure initiatives, as well as the use of the order set, is one of the key strategies to improve heart failure care," she adds.
If a particular physician isn't using the order set, the heart failure physician champion at that facility intervenes and conducts individual education to improve the use.
The care coordinators and staff nurses identify patients being admitted with heart failure and make sure the heart failure order set is on the chart.
Heart failure offers one of the greatest opportunities for medication reconciliation and education, Stafford points out.
"These patients are often on many medications and may be confused about how to take them properly. Although there is not just one intervention that decreases readmission, ensuring the patient has his or her medications and understands how to take them is very important," she says.
At Baylor, medication reconciliation starts in the emergency department, where the admitting physician is responsible for reviewing the medications on admission. When a patient is transferred from one unit to another, the pharmacy department sends a list of current medications so the physician can check off which ones to continue.
At discharge, the physician and the discharge nurse are both responsible for reviewing the medication list and explaining it to the patients.
At Baylor, the staff nurses are responsible for patient education and use a standardized array of patient education tools, including packets of information and videos on the hospital's television channel.
"The teach-back model for patient education confirms that the patient understands the inpatient and discharge instructions. Rather than just giving them information to read, we ask them to repeat or explain it to us to ensure we know they understand. This technique is more effective than just giving them a booklet or folder of information," she says.
Another strategy is to give the patient a contact person's telephone number, such as the number of the nurse manager on the unit from which he or she was discharged.
"We encourage them to call if they have any questions or are confused about their discharge instructions," she says.
When it comes to setting up post-discharge appointments, the patient often is the roadblock when the staff try to facilitate a follow-up appointment, Stafford says.
"Many times patients want to speak to their family members to schedule an appointment at a time when the family member can provide transportation. It's very difficult to set up an appointment that is acceptable to the patient before he or she is discharged," she says.
Recognizing that it's often difficult for patients to get a follow-up appointment in a timely manner, the heart failure team at Baylor Medical Center in Garland, TX, has arranged with a large physician group, Health Texas Physician Network, to work in appointments for heart failure patients within three to five days of discharge.
"The handoff and that connection are really important," Stafford says.
Another strategy used by the Baylor Health Care System is a process whereby care coordinators identify patients at high risk for readmission and hold daily huddles to discuss the patients' discharge planning with a member of the nursing staff and social workers. The process includes post-discharge phone calls to make sure the patients have follow-up appointments and to discuss symptoms and medication.
"The process is not widespread because of the resources needed to conduct the phone calls properly. Understandably, when the inpatient staff discharge their patient, their eyes turn to the next patient in that bed. In health care, we all are going to have to realize that we are responsible for the patient's transition in care," she says.
The hospital system is piloting a transitional care model developed by Mary Naylor, PhD, RN, at the University of Pennsylvania School of Nursing that uses advanced practice nurses to coordinate care after discharge.
"The nurses see the patients in the hospital and develop a relationship with the patients and their physician, then coordinate the care as the patient leaves the hospital. They see the patients in their homes within 24 hours of discharge and accompany them to the first physician appointment," she says.
During the pilot, which began at Baylor Medical Center in Garland in August, the advanced practice nurses will follow the patient for up to three months.
"The nurses will help facilitate chronic care management and act as an advocate to keep the patients on track and help manage their symptoms. This new model should improve all our outcomes, including 30-day mortality and readmission rates," Stafford says.
Baylor has assembled palliative care teams at each hospital so the physicians can call on them to talk with the patient and families about end-of-life issues and hospice care.
"Physicians typically are not comfortable with broaching the subject of end of life with their patients," Stafford says.
One of the smaller community hospitals in the Baylor system had a high mortality and readmission rate for heart failure. The hospital looked for causes and determined that one reason was that the nursing homes in the area were transferring patients to the hospital to die.
The team at that hospital worked closely with the nursing homes to institute appropriate palliative care or hospice for patients with end-stage heart failure. The initiative improved the quality of life for the patients and kept them out of the hospital.
When the Centers for Medicare & Medicaid Services (CMS) analyzed hospital readmission rates to post them on the Hospital Compare web site, the lowest heart failure readmission rate in the nation was at the Baylor Jack and Jane Hamilton Heart and Vascular Hospital.Subscribe Now for Access
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