Education, follow-up reduce readmissions

Use of Heart Failure Zones is a key

A pilot project providing coaching and follow up for heart failure (HF) patients who are readmitted frequently resulted in a 50% drop in the readmission rate at Indiana University (IU) Health Ball Memorial Hospital in Muncie, IN.

The pilot project focused on patients admitted by the hospitalist team, which admits most patients at the 350-bed hospital, says Traci Strauch, RN, BSN, RN case manager. Strauch and Patty Williams, RN, BSN, CCM, lead RN case manager manage the care of patients being followed by the hospitalist team.

Williams says, "We were pulled off the unit two years ago when the hospital-based hospitalist program was begun."

The project originated when Pat Gorman, RN, MSN, CPHQ, administrative director for the hospital who oversees case management, asked Strauch and Williams to develop and carry out a project to focus on heart failure patients who were readmitted frequently. Based on the success of the pilot, the hospital has since hired a full-time heart failure coach, Wilma Carrier, RN, BSN, case manager. In the future, the hospital will roll out the program to include patients on the cardiac telemetry unit, regardless of who admits them. Strauch and Williams act as back-up coaches and fill in when Carrier is on vacation.

The program provides intensive education throughout the patient's stay, follow-up within 48 to 72 hours after discharge, and weekly calls for the next four weeks for patients who are discharged to home, as well as those going to skilled nursing facilities or assisted living facilities.

Williams says that when a patient with heart failure is admitted, the case managers meet with them, discuss the reasons for admissions, and begin the educational process. "They visit the patient throughout the stay, teaching them about their medication and diet, determining their home situation and support system, and assessing their need for medication assistance. Then they start educating the patient on the plan to follow after discharge," she says.

Strauch adds, "In every encounter, we use teach-back questions to make sure they understand the disease process and their treatment plan. We ask if they're following their diet and if they are having any problems."

After discharge, the case managers call the patients within 48-72 hours to make sure they have filled their prescriptions, to make sure that they have a follow-up appointment with their primary care physicians and/or specialists if needed, and to reinforce the discharge teaching they began on the unit. After that call, they call the patients on a weekly basis and go through the treatment plan.

A key component of the program is teaching patients how to use the Heart Failure Zones, a one-page tool that uses the colors of the stoplight to help patients learn to manage their condition. The Green Zone means symptoms are under control. The Yellow Zone lists shortness of breath, swelling in feet and ankles, some weight gain, and other symptoms, and it instructs patients to call their doctor. Symptoms in the Red Zone alert patients to seek emergent care and include difficulty in breathing, chest pain, and confusion.

Everyone on the treatment team educates the patients on the heart failure zones. The nurse caring for the patients has them explain each day how they feel and correlate it to the zones and the patient's weight. Williams says, "This way, when they go home, they know what symptoms to look for and what to do if they occur, which helps them avoid an exacerbation that could bring them back to the hospital."

Strauch says the project gave the hospital case managers a chance to develop close working relationships with home health agencies and skilled care facilities. "We don't limit telephone calls to patients who go home," she says. "We also call the skilled care or assisted living facilities."

The hospital invited home care agencies with telehealth and heart failure disease management programs to become part of the team and learn about the zones so the patients receive the same information after discharge as they receive in the hospital. "We educated our skilled care facilities on the zones and send a Heart Failure Zones sheet with the patients who are discharged to nursing facilities," Strauch says.

The team revised its skilled nursing facility order sets, adding one for heart failure that specifies weighing the patients every day, putting them on a low sodium diet, and giving them a rescue dose of furesomide if they gain 2 pounds in 24 hours.

Willliams says: "We're continuing to looking at going outside the hospital walls to coordinate patient care. We have placed social workers in some of our clinics and assigned an RN case manager to the at-risk population in the hospital's insurance group."


• Patty Williams, RN, BSN, CCM, Lead RN Case Manager Indiana University Health Ball Memorial Hospital in Muncie, IN. E-mail:

Heart Failure Zones were developed by Improving Chronic Illness Care, a Robert Wood Johnson Foundation program housed at the MacColl Institute for Healthcare Innovation in Seattle. For more information, visit Click on "Resource Library," then on the left side of the page, select "Critical Tools" and "Red-Yellow-Green CHF tool."