Home care nurses help patients avoid readmission

Hospital, agency collaborate to ensure safe transition

In an effort to ensure that the patients most vulnerable for readmission stay safe at home after discharge, Lutheran Medical Center is developing a pilot program with a local home care agency to provide at least one home care visit for the majority of congestive heart failure patients going home with no services.

"The literature says that patients who don't see a doctor within seven days and who are unclear about their medication or diet are at the highest risk for readmissions. The patients who are sent home with no services are those who fall through the cracks," says Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at the Brooklyn, NY, hospital.

Home care nurses can determine if the patient is following his or treatment plan, taking medication properly, and is scheduled for follow-up care, she points out.

The hospital is collaborating with Visiting Nurse Services of New York to provide follow-up visits for patients who have congestive heart failure and plans to expand the program to include patients hospitalized for acute myocardial infarction and pneumonia, Cesta says.

The average patient with heart failure is elderly, is likely to be hard of hearing, with poor eyesight. He or she may be experiencing memory loss and is likely to have problems understanding his or her discharge instructions and following them, Cesta says.

"We're dealing with very short lengths of stays and no longer have the luxury of time to go over and over what the patient needs to do after discharge. The visiting nurse can make sure they understand their treatment plan and that they understand their medication," she explains.

Visiting Nurse Services of New York has developed similar programs in collaboration with other New York hospitals, says Elaine Keane, vice president for business development for the home care organization.

"This is the kind of program that you don't just take off the shelf. It has to be a collaborative effort between the hospital and the home care agency. For this to be successful, both of us have to sit down at the table and work together," she says.

The team from the home health agency works closely with the hospital to identify patients who will be referred for the home care interventions and to develop treatment protocols to plug the gaps in care, Keane says.

"The essence of this program is to provide intensive services to a vulnerable population and to determine which will need services in the home after discharge. This is a special program with a different protocol from our usual home care protocols. We work with each hospital's staff to develop treatment protocols for these patients," she explains.

Patients who are at risk for hospitalization receive intensive education from the visiting nurses while they are in the hospital. This education augments the education the hospital's case managers are providing, Keane says.

Those who are at high risk for readmission receive education and reinforcement in the home after discharge, she says.

"We work with the patients and their caregivers to develop treatment goals and a plan for what the patients should do if the symptoms present," Keane says.

Medication reconciliation often is a big issue with heart failure patients. The visiting nurses work with the patients to ensure that they are taking the right medications and are complying with their medication regimen, but the hospital also plays a role, she reports.

"The hospital has to make sure the patient's medications are available upon discharge and that the patient understands how to take them. In addition, the hospital has to ensure that the treating physician in the community has a copy of the patient's medication list to avoid duplicate prescriptions," Keane says.

The visiting nurses make sure that the patients have a follow-up appointment and they keep them.

"We need the support of the hospital to ensure that patients can get an appointment within seven days. The hospital has a big role to help patients see a doctor in their clinics," she says.

The key to the success of the program is close collaboration between the hospital and the home care agency, Keane points out.

"Health care is a series of handoffs and transitions. We need to promote a seamless transfer of information to make the handoff work. We work with the hospital to determine why the readmissions are occurring and work together on areas where there are gaps in care," she says.