Executive Summary

In a pilot study, coronary artery bypass grafting surgery patients who were in North Shore University Hospital’s Follow Your Heart program had a 3.85% 30-day readmission rate compared to a 11.54% rate for at-risk patients not in the program.

  • Cardiac surgery nurse practitioners visit at-risk patients at home after discharge, conduct a physical exam, performed medication reconciliation, and educate patients on signs and symptoms that indicate they should call their doctor.
  • They collaborate with the home health nurses, informing them about what happened during the hospital stay and sharing other information that might not be on the discharge summary.
  • They send a report of the visit to the patient’s primary care physician, surgeon, and the home health agency.

At-risk patients who received at least one home visit by a cardiac surgery nurse practitioner after coronary artery bypass grafting surgery at North Shore University Hospital in Manhasset, NY, had less than a third the number of readmissions within 30 days as patients with similar demographic and medical conditions who did not receive the interventions, a pilot study showed.

In the pilot study, 3.85% of patients in the Follow Your Heart program were readmitted to the hospital within 30 days compared to 11.54% of at-risk patients who did not receive the interventions.

Following the success of the pilot, the North Shore-LIJ Health System expanded the program to include three hospitals, says Michael H. Hall, MD, MBA, division chief of adult cardiac surgery at North Shore University Hospital.

The Follow Your Heart program evolved over several years as the North Shore-LIJ Health System began looking at ways to improve transitions and reduce readmissions, says Hall.

“We determined that people who have the most support and the highest socioeconomic status tend to do well after discharge. They don’t have a problem getting to the doctor for a follow-up visit or figuring out the medication regimen,” Hall says. Patients whose only income is Social Security benefits and who have little or no support at home are at highest risk, he says.

“People without support don’t have anyone to get their prescriptions filled or to take them to their follow-up appointment, so even if we made the appointments for them, they didn’t go,” he says.

All coronary artery bypass surgery patients have visiting nurse services after discharge, but the nurses don’t know everything that happened during the hospitalization, such as any medications that the patient couldn’t tolerate or the circumstances surrounding the need for the surgery, Hall says.

“Some important details don’t get transmitted when patients transition between levels of care. Physicians and nurses may write things but they may not be fully understood,” he says.

For instance, the home health nurse may notice that a patient’s ankles are swollen and send him back to the hospital or to visit his doctor. But the nurse has no way of knowing that the swelling was much worse in the hospital and that the patient actually is getting better, Hall says.

The nurse practitioners who see patients in the hospital around the clock know what has happened with the patients, what problems they had, what medications they are on, and other details that may not make it into the discharge summary, Hall says.

“The nurse practitioners work with the visiting nurses to get them up to speed on the patients. It has made a big difference in the quality of the hand-off. When care providers know the patients, they are in a better position to help them through the transition,” he says.

The nurse practitioners get the patients’ permission for the visits before they leave the hospital. “Most are happy to have someone check up on them. They find it very reassuring,” he says.

The nurse practitioners are assigned to visit the patients in the home based on where the patients live in relation to where the nurse practitioners live. Most of them make the visits on their way home from work. The visits last about an hour.

The nurses visit the patients at least once after discharge and sometimes twice. The nurse practitioners conduct a physical exam, check out the incision, and take vital signs. They go over the medications and make sure the patients are taking the right ones at the right time. They can adjust the medications if necessary. They educate the patients on taking their medicine, watching their diet, and signs and symptoms that indicate their condition may be worsening.

“The patients know the nurse practitioners, and they are more likely to listen to their advice and to communicate things they might not tell someone they just met,” he says.

At the end of the visit, the nurse practitioners send a report of their visit to the patient’s primary care physicians, the surgeon, and the visiting nurse agency.

The nurse practitioners visit the patients once the first week after discharge and again the second week in some cases. They follow up by telephone and are available if the visiting nurse has any questions or concerns.

“The nurse practitioners are the key to this program’s success because they provide patients they know from the hospital setting with the continuity of care they need after discharge. We hope to continue our studies with other medical diagnoses, such as heart failure, and determine the most efficient way for excellent, cost-efficient, and sustainable long-term care for these patients,” Hall says.