Critical Path Network

Elderly heart failure patients get help at home

Hospital partners with community coalition

Elderly heart failure patients who are at risk for rehospitalization are getting help following their treatment plan after discharge through a collaborative effort of The Methodist Hospital in Houston and Care for Elders, a community coalition of 80 private and public agencies that develops and tests pilot projects serving older adults.

The Hospital to Home program, which was kicked off in June 2009, provides a transition coach who goes into the home shortly after elderly patients are released from the hospital, educates them about their treatment plan, and works with them on self-management techniques, says Lynda Collins, MSSW, LCSW, director of continuity of care for The Methodist Hospital.

"Care for Elders has been working to improve the Harris County systems that provide care for the elderly for five or six years. When they received a grant to develop the transition of care program, they picked Methodist as the hospital partner," she reports.

The program is one of several initiatives established by the hospital's continuity-of-care department in an effort to improve transitions throughout the continuum of care and reduce readmissions.

"Frequent fliers are a symptom of a broken system. Patients are asked to coordinate their own care after discharge, and not all of them can handle it. They often show up back at the hospital. We need to change the way we deliver care," Collins says.

Targeting HF patients

The program started with heart failure because those patients have the biggest risk of being readmitted to the hospital, she adds.

The goal of the program is to demonstrate improved quality, reduced readmissions, and fewer emergency department visits for patients in the program.

"If the program is a success, we hope that it can expand to include other diagnoses. Since the Centers for Medicare & Medicaid Services announced its intention to hold hospitals accountable for readmissions within 30 days, plans to expand the program have been gaining momentum," Collins says.

The Hospital to Home program is based on the Care Transitions Program developed by Eric Coleman, MD, MPH, professor of medicine in the division of health care policy and research at the University of Colorado Denver.

Heart failure patients who are treated at The Methodist Hospital and are at risk for readmission are referred to the program by the hospital's case managers, nurse practitioners, cardiologists, and other staff members.

Collins' department and other members of the Care for Elders Coalition developed criteria to guide the referring clinicians.

For instance, patients with memory problems, those who have a history of failing to adhere to the treatment plan, patients with an impaired spouse, and patients who have an elderly caregiver are eligible for the program.

The program uses community-based transition coaches to work with the patients in their homes.

"The community-based transition coaches bring additional knowledge and skill sets that hospital-based transition coaches may not have," she says.

The transition coach for the Houston program is a social worker based at Sheltering Arms Senior Services, a nonprofit agency that specializes in helping people stay in their homes.

Extensive education

The hospital provided extensive education on heart failure for the transition coach, including medication reconciliation, symptom management, and self-care.

"Our protocol is for the patients to receive a home visit for six months. The transition coach visits or calls patients in their home at least once a week for the first three weeks, then tapers off based on need. She may follow up in person or on the telephone," she says.

The purpose of the program is to bridge the gaps in care that often occur when patients are overwhelmed by discharge instructions while they are in the hospital setting.

"Our hospital has excellent heart failure educators who see every patient. We have developed clearly written printed materials that explain what patients should do after discharge. However, the patients aren't feeling well when they are in the hospital; they're anxious, eager to get home, and they don't always remember everything," she says.

In addition, patients and family members may have vision or hearing problems that also make it difficult to follow the treatment plan, she says.

"The one time in people's lives when they have to learn all this new information is the time of life when things are difficult to comprehend because of aging and health issues," she says.

Many patients have multiple problems but are treated by specialists who look at just one problem. This leads to fragmentation in the care patients receive and often confuses patients.

"They may have been seen by several physicians who gave different discharge instructions, and they may have a long list of different medications prescribed by different physicians," Collins says.

Reviewing meds

When the transition coach visits patients in the home, the first thing she does is look over the materials the patient brought home from the hospital. She asks patients to bring out all their medications, goes through them, and asks how often they take the medicine and determines if they know why they are taking it.

The transition coach writes down the medication on a reconciliation document and faxes it to a clinical pharmacist for review.

"They evaluate every patient to see if they have a system for adhering to the treatment plan that works," she says.

"Their goal is to find out if they understand their medication and to learn how they are really taking it. Sometimes the patients haven't gotten their prescription filled because they can't afford it. In that case, the coach finds a way to get the medication," she says.

"The program is a patient self-management program with a goal of activating the patients' skills in caring for themselves and complying with their treatment plan. Since it takes place in the home, the patients are comfortable and at ease and not anxious like they are in the hospital. The transition coach is able to determine what the patients really remember," she says.

(For more information, contact: Lynda Collins, MSSW, LCSW, Director of Continuity of Care, The Methodist Hospital, Houston, e-mail: