Coaching helps cut readmissions

Face-to-face encounters included

A year after Saint Joseph-London Hospital in London, KY, began a heart failure readmissions program, 30-day readmissions dropped from 27.7% to 15.9%. A similar program for patients admitted for acute myocardial infarctions (AMI) reduced the readmissions rate from 23% to 10% in a short time.

A study of the reasons for readmissions showed that variation in discharge plans and lack of patient preparation for managing their care were the main reasons for the readmissions, says Mary Osborne, RN, MSN, MBA, executive director of Innovative Cardiac Solutions, a management company with which the hospital contracts to manage its cardiac service line. The hospital serves five counties in the Appalachian region of southeast Kentucky. Those counties are in a rural area with low income levels and high rates of obesity, coronary artery disease, and diabetes. Cardiology represents about 65% of hospital business, Osborne adds.

The program includes face-to-face encounters with patients by Shalan Gibbs, RN, BSN, the hospital's heart failure and AMI transition coach, who visits them in the hospital, calls them after discharge, and sees them in the heart failure and AMI clinics within a week after discharge. The clinics are run by mid-level providers who see patients only once or twice during the 30 days following discharge.

"We aren't trying to replace the primary care physicians or cardiologists in the community," Osborne says. "The clinic supports patients through the acute phase of recovery."

Gibbs attributes the success of the program to meeting patients face-to-face and getting to know them. "We establish rapport before the patient leaves the hospital," she says. "They know I'll call and see them at the clinic, and they know they can call me any time. I still get calls from some patients who have questions months after discharge."

The hospital started the program in mid-2010 and focused on heart failure patients initially, then rolled it out to include AMI patients. Each day, Gibbs reviews the entire hospital census to identify heart failure patient and AMI patients. She visits them, usually on the second day of the hospital stay, to educate them on their disease process and to review their diet, medication, and other parts of the treatment plan. With AMI patients, she usually waits to see what kind of intervention they are having so she knows what kind of education they will need. She often sees patients having a coronary artery bypass graft before discharge.

"I work hand in hand with the case managers to get patients ready for discharge," Gibbs says. "The difference is that I have the time to sit down and talk to them for as long as needed, whereas the case managers have other jobs to do as well as educating patients. I stress to them that they can call me when they get home if they are having any problems or have questions."

If patients qualify for home health services, Gibbs follows up with the patients to make sure services are coordinated. "If they don't have a primary care physician, I make sure they have one before they are discharged," she says. Gibbs sets up an appointment with the heart failure or AMI clinic within a week of discharge. "Many patients who are readmitted come back within the first seven days. We like to see them in the clinic to take care of any issues that could cause a readmission," she says.

Gibbs calls the patients within 72 hours after discharge and goes over their treatment plan and their medication regimen, and she makes sure they have scheduled an appointment with their primary care physician in addition to the clinic visit. "If they aren't following their discharge plan, I determine what the barrier is and work to overcome it," she says. Many times, patients didn't fill their prescriptions because they couldn't afford it. In those cases, Gibbs helps them sign up for the hospital's pharmaceutical assistance program, which helps patients who qualify obtain heart and diabetic medicines.

According to Osborne, about 90% of patients who visit the heart failure clinic need a medication adjustment. "We can get the medication adjusted early and avoid problems down the road," she adds.

With heart failure patients, the biggest roadblock to compliance is diet. Gibbs says, "I pull up a footstool and sit next to the bed and talk about what they like to eat. By making small talk, I usually can pick up where the problems are."

Gibbs gives heart failure patients a list of foods they should avoid. She urges them to get rid of their salt shaker, and she shares recipes and seasonings that can substitute for salt. "Many patients are elderly and eat things that are quick and easy to prepare but are chocked full of sodium," Gibbs says. "Canned soup is what lands a lot of people back in the hospital. I suggest that they look for low sodium soup. It still has a lot of sodium, but at least they are cutting back."

A year after the program started, most of the heart failure readmissions are patients with end-stage disease, Osborne says. "We are working to get them referred to hospice care if that is appropriate," she says. "It's been a challenge because thinking about hospice is so difficult for patients and their families."

Many of the heart failure patients already have Medicare and/or Medicaid. AMI patients frequently are younger and many have no insurance. About 80% of the AMI patients did not know they had a heart problem until they came to the hospital. Gibbs says, "It's a totally new experience for them. They tend to be more compliant about that than heart failure patients because of the fear that comes with having a heart attack, but they need far more resources."

Many of the patients are self-pay and don't follow up with their physician or get their prescriptions filled because they can't afford it, she says. A hospital social worker is called in and gives them a voucher for two weeks supply until the medication from the pharmaceutical assistance program is available.

Gibbs visits them after their interventions and goes over their treatment plan with them. She discusses the need to exercise, and she educates them on a heart healthy diet. Gibbs asks them to sign a contract agreeing to take their medication and follow their treatment plan.

"I educate them on why it's important to take their medication and urge them to call me if they run out and can't get it," she says.


• Mary Osborne, RN, MSN, MBA, Executive Director of Innovative Cardiac Solutions, London, KY. E-mail: