Heart failure program cuts readmissions

CMs visit patients in their homes

In the first 10 months of the Heart Failure Transition Care Program at Tucson, AZ-based Carondelet Health Network, case managers, called nurse partners, prevented hospital readmissions 14 times while managing the care of 62 high-risk patients.

Participants in the program were readmitted to the hospital seven times between October 2010 and August 2011, mostly because they were end-stage heart failure patients. Among the 21 eligible patients who refused to participate or whose physician did not recommend it, 16 were readmitted, according to Rose Quiroga, RN, BSN, one of two nurse partners in the program.

The nurse partners work with the patients in their homes. They help them overcome barriers to care and adhere to their treatment plan. They visit the patients two to three times a week during the first few weeks after discharge, then gradually taper off.

It's the home visits that make the difference in the program, Quiroga says. "We started out doing telephonic case management, but it's not the same. In the home, we can see the situations in which the patients live and what kind of food they're eating. We can see that a patient's feet are swelling or that he is out of breath and can call or text their cardiologist," she says.

The program originally was designed to follow patients for two to three months, but some patients stay in the program longer. A number of patients have been in the program for about five months, then transitioned to a telephonic program.

Most of the patients in the program are out of work with no insurance. Others are the working poor and do not qualify for Medicaid. Some are undocumented immigrants or homeless. Many have little support at home and have been readmitted repeatedly because of the challenges they face in following their treatment plan. About 25% of the patients in the program are younger than age 60.

Amy Salgado, RN, MS, nurse partner says: "These patients have numerous social issues, and we spend the better part of the first month trying to help them get the services they need. We have to deal with the social issues before we can start the heart failure teaching."

The nurse partners work with patients who are hospitalized at three Carondelet facilities in the Tucson area. Quiroga manages the care of patients at Carondelet St. Mary's Hospital, while Salgado sees patients hospitalized at Carondelet St. Joseph's Hospital. They both see patients at the Carondelet Heart and Vascular Institute.

They have developed close relationships with the cardiologists and hospital-based case managers, and receive most of their referrals from them. Whenever possible, they visit the patients while they are in the hospital, explain the program, and have them sign a consent form if they agree to participate. "We start educating patients while they are in the hospital, working with the nurses and case managers on the floor. We try to get patients accustomed to checking their weight every day and entering it into a log while they are still in the hospital," Salgado says.

Quiroga reports that the nurse partners complete a detailed nursing assessment while the patients are still in the hospital. "The assessment helps us learn the challenges the patients will face in managing their own care and identify the kind of support they're going to need," she says. The nurse partners educate the patients on their disease, their treatment plan, and their medication regimen. "We want to help people take control of their disease and learn how to manage it better," Quiroga says.

Medication reconciliation is one of the first tasks the nurse partners tackle on the first visit to a patient's home. Salgado says, "Many of the patients are really confused about their medication. We compare the old and new medication and show them which to take." The nurse partners show the patients how to fill a pill box with their medications. The second week, they watch the patient fill the box to make sure they know how to do it.

"Some are still extremely ill the first few weeks and need extra help. I work with them until they feel well enough to take over," Salgado says.

The nurses go through the patients' kitchen cabinets and refrigerators and help them learn which foods they can't eat because of the sodium content. "We help them come up with a menu for each day and connect them with the resources they need to get food. If patients can't make their own meals, we connect them with Meals on Wheels to provide a low- sodium diet," Salgado says.

The nurse partners accompany patients when they visit their primary care physician, cardiologist, pulmonologist, or other specialist. Quiroga says: "Many of our patients don't have anyone to go with them and are confused about what they should do. We can be another set of ears and explain what the doctor said," she says. (For more information about the Heart Failure Transition Care Program, see article above.)

Nurses help HF patients with basic needs

Low-income patients need extra help

Taking care of patients' basic needs such as obtaining food, transportation, and medication is the first priority of the case managers, known as health partners, in the Heart Failure Transition Care Program at Carondelet Health Network in Tucson, AZ.

The health partners visit the homes of heart failure patients at risk for readmissions and help them learn to navigate the healthcare system and follow their post-discharge treatment plan. Many of the patients in the program are low income or out of work and are barely making ends meet. Amy Salgado, RN, MS, nurse partner says, "Many of our patients are more worried about how they are going to pay the rent or their utility bills than about taking care of their own health.

It often takes as long as a month to take care of the patient's social needs so they can concentrate on learning about how to manage their disease, says Rose Quiroga, RN, BSN, one of two nurse partners. The nurse partners refer patients to social agencies in the Tucson area. Many are referred to the St. Elizabeth Health Center, a community health clinic that provides care for the uninsured and underinsured and helps them sign up for food stamps and other programs. "Many of these patients don't qualify for food stamps and can't get to a food pantry because they don't have transportation or money to catch the bus. In that case, we bring food boxes to them," Quiroga says.

Salgado tells of working with one patient who has a job paying $8 an hour, but only when he works. "He didn't get paid for the week he was hospitalized or when he was recovering at home and was behind in his bills. He felt he couldn't take a couple of hours off to see the doctor," Salgado says. She got him free medication, boxes from the food pantry, and assistance with paying his rent and his utilities.

One patient who did not have a telephone ran out of medication and couldn't afford more. He walked to a pay phone and called Salgado, who intervened to have his cardiologist give him samples until he could sign up for medication assistance.

"If he hadn't called, he would have ended up back in the hospital," she says. "These patients want to keep their disease under control. They just need a lot of support."