Heart failure rates cut after initiative

Education, follow-up are keys

After Charleston (WV) Area Medical Center began a readmission reduction program, readmission rates for a group of targeted heart failure patients was reduced by 50%.

The reductions are directly tied to better educating the patients while they are in the hospital, ensuring that they have a timely follow-up visit with a primary care physician, calling them after discharge to make sure they understand and are following their discharge plan, and improving transitions to post-acute providers, says Dale Wood, MBA, MHA, vice president and chief quality officer for the 838-bed tertiary care hospital. The program is focusing on heart failure patients, but the hospital plans to expand the initiative to include patients hospitalized with pneumonia and acute myocardial infarction, he adds.

"We knew that patients needed to see primary care physicians shortly after discharge and that heart failure patients needed to understand their medication regimen and the importance of weighing themselves daily. We assembled a multidisciplinary team to focus team on what we needed to change in order to prevent patients from coming back to the hospital," Wood says. (For a look at what the team did, see related article, below.)

At Charleston Area Medical Center, case managers are assigned by unit and are paired with a social worker. They handle utilization review, discharge planning, and care coordination. When patients are readmitted, a case manager interviews them and reviews the chart to determine why they were readmitted. The case managers determined that many patients were coming back because of poor support at home, says Leigh Ann Stone, ADN, MHA, director for case management. "We found that the education needed to be beefed up while the patients were in the hospital," Stone says. "We needed to get a referral for home health services for appropriate patients so they would have more support after discharge and to better educate the family as well."

Early in the stay, case managers determine if patients have a primary care physician, and help those without a medical home identify a physician. Whenever possible, the case managers call primary care physician offices to set up post-discharge appointments before patients leave the hospital. When patients don't have a primary care provider or can't get a timely appointment, the case managers arrange an appointment at a special heart failure clinic the hospital set up at one of its urgent care facilities. "The clinic has a separate entrance and is open one day a week for follow-up care," Wood says.

The medical director for the hospitalist team and other physicians on the steering committee contacted all of the primary care physicians in the community to find out what information they need from the hospital to provide follow up care for patients. The Partners in Health team contacted providers and critical access hospitals throughout the state to ensure that patients get the follow-up and support they need when they return to their home communities.

The team implemented a computerized system to call heart failure patients after discharge and ask a series of questions. The nurses tell the patients to expect a call and tell them what will show up on caller ID to make sure they'll answer the phone. About 80% of patients who are called answer the questions.

Based on their answers, a hospitalist or nurse is alerted and calls the patient, gets more information and determines whether the medication can be adjusted, or if the patient needs to visit his or her doctor, or come to the emergency department.

Wood says, "We know that heart failure patients are likely to be readmitted but this program helps them stay healthy longer. We're also freeing up hospital beds for other patients and saving money for patients and the insurance companies."


For more information contact:

  • Dale Wood, MBA, MHA, Vice President and Chief Quality Officer, Charleston Area Medical Center, Charleston, WV. E-mail: dale.wood@camc.org.

Hospital-wide team revamped processes

Before Charleston (WV) Area Medical Center started its initiative to reduce readmissions, the executive team appointed a multidisciplinary steering committee to review the elements of successful readmission reduction programs throughout the country. The committee set up subcommittees to focus on how to adapt each component to meet the specific needs of the hospital.

The committee included Leigh Ann Stone, ADN, MHA, director for case management, the physician advisor for case management, the medical director for the hospitalist team, the manager of the hospital's urgent care clinic, the clinical director of the medical service line, and the medical director for the hospital's Partners in Health program, a collaboration of representatives from other hospitals from across the state that transfer patients to Charleston Area Medical Center for treatment and federally qualified health centers in communities throughout West Virginia. Two master black belts from the hospital's Six Sigma department served on the steering committee to help facilitate projects.

An education subcommittee which included representatives from case management, social work, and nursing, reviewed the thick packets of educational material the hospital was giving to patients and concluded that the material was so lengthy that few patients were likely to read it all the way through. In additional to simplifying the patient education material, the subcommittee created a one-page, color-coded educational sheet that patients can place on their refrigerator or bathroom mirror. Based on the Heart Failure Zones concept, it tells patients what they should do every day to manage their condition and instructs them on what to do when they have certain symptoms.

Another subcommittee looked at improving transitions across the continuum. Stone and the physician advisor for case management set up a meeting with skilled nursing facility representatives to discuss ways to work together to provide better care. Based on their input, the hospital subcommittee worked on changing the order sets to better facilitate patient care, Stone says. For example, the facilities wanted more specific information on how long patients needed to be on certain medications.

"The skilled nursing facilities told us that they were not always getting information when a patient is transferred. We have worked on getting the discharge notes and specialty dictation sent in a timely manner," Stone says.