Readmission rates for HF reduced by 30%

Transitional care model, self-management keys

DMC Sinai-Grace Hospital in Detroit has been recognized by the Institute for Healthcare Improvement (IHI) for reducing its heart failure readmission rate by 30% this past year. Sinai-Grace was one of the first hospitals to participate in the IHI's State Action on Avoidable Rehospitalizations (MI STAAR) initiative.

"We received a letter in 2009 stating that IHI and the Michigan Hospital Association were doing a joint venture on reducing hospital readmissions," says Peggy Segura, FNP-BC, nurse practitioner and the day-to-day leader for the STAAR project. "Our president and my boss decided this was something they were interested in."

While the initiative offered guidelines, she says, "we picked what we wanted to work on first." The project leaders looked at the highest-impact areas, processes that were in place, and what could be improved upon with the greatest impact. "For us, congestive heart failure had a significant readmission rate; in fact, most participants have selected it because it's one of the highest DRGs," says Segura.

Transitional care focus

The key component of the initiative, says Segura, was the transitional care model. "That involves providing a high level of service — whether from the acute facility to home or rehab, or back to the primary care provider," she explains. The other key element, which supports the first, involved improving the self-management of patients with chronic diseases.

"We found the most important activity was finding who the learner was; sometimes it's not the patient, but a family member or caregiver; sometimes it's a combination," says Segura. "If the patient is not the one who's going to the store and purchasing food or meds, we need to make it a joint venture."

Within the first 24 hours of admission, an advanced learning assessment is conducted by the nursing staff, the case management staff, or Segura herself. "We educate the patient by teach back; we identify the key points we want to teach them about their disease process and communicate with them at a 5th grade reading level," she says.

The goal, she says, is to make sure the patient/learner understands who the primary care provider is, what his or her medications are, and how frequently they should be taken. "We also teach them what they're used for, and that they have to have two lists of medications — one with them and one at home," Segura adds. "For this disease process, we also wanted to teach signs and symptoms of their condition worsening — identifying when they are going into heart failure, and what they need to do if it happens. And, we teach them about follow up."

Teach back, she explains, is a "non-shaming" way of teaching patients. "Studies have found if you ask close-ended questions, they give you close-ended answers," says Segura. "We tell them at the end of the session that we want them to teach the information back us to be sure we both have an understanding."

Other improvements implemented

The program involved several other process improvements, including post-discharge follow up. "We have a call center in the hospital, so upon discharge we provide patients with a request for a follow-up appointment to be made within five days," says Segura. "We make sure they have available transportation, and that it works within their schedule."

Initially, she says, her team would call the patients on days seven, 14, 21, and 28 post-discharge to make sure all was going well — that they had followed up with their primary care doctor, and that they were taking their medications. "We also verified the teach back," Segura adds.

However, they found that a number of readmissions were occurring within the first 13 or 14 days, so the call program was rescheduled for days three, eight, 13, and 25. "At the end of 30 days, we turn the patient over to the corporate call center nurses, who call the patients at home twice a month for six months," says Segura.

Improved coordination of care, she continues, goes hand in hand with the post-discharge follow up. "We make sure to facilitate getting the patient back to their primary care provider," says Segura. "If they're from another system outside of ours, we still make every attempt to do follow up. We also work closely with home care and we partner with the Visiting Nurse Association on telephone monitoring, and they call me if the patient is in trouble."

If patients do not have a primary care provider and they are insured, the team asks them who they want to follow up with. "Most of the time they choose to see their [Sinai-Grace] doctor if they have an office outside the hospital," she says. "If they're uninsured, I see the patient in our primary care clinic, and they see me at no charge."

Finally, says Segura, medication reconciliation also has been improved. "We have an EMR, and the medical history is obtained by a nurse at the point of entry," she explains. "Then, whoever provides the care will reconcile the medications. We do an admission reconciliation, and they verify with the patient that those are the meds they're on. If they're transferred to another unit, a transfer reconciliation is obtained, and a discharge medication reconciliation is completed at discharge on a written form."

As most prescriptions come with a label, she continues, "I try to teach my patients to take that label and put it on a loose-leaf piece of paper along with the name of the person who wrote the prescription, where it gets filled, and the last time it was filled."

Keys to success

The project could not have succeeded, says Segura, without the support of top administration. "It had to come from the top down," she says. "Once they decided to support the initiative, they allowed my boss to hire 1.5 people and a QI specialist [Segura came on board about three weeks before the project was implemented]. Once the plan was formulated, I worked with a unit to pilot on, along with unit managers and the administrative director." The team, she says, included a member from pharmacy, primary care clinic managers, social workers, two QI specialists, and a nurse educator, all of whom went to the "kickoff" to get educated on the total program.

When she came on board, Segura went through the process herself. "I went to the floor and educated patients for a month," she recalls. "Then I started bringing in nurse champions for each unit; I educated them, and we worked with the patients. Once they were comfortable, we expanded to teaching on the floors."

Another key to success, she says, is having someone who is very knowledgeable and practice driven — in this case, her boss. "She looked at the project and defined the process, and developed a process map," she says. "We looked at who was responsible for each process; it's really a matter of putting the right people in the right place."

Segura says she is convinced that facilities that have not been as successful "did not have a defined process, or a defined leader."