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Team targets readmission for heart failure patients
Program reduces rate to just 17%
After St. Luke's Hospital in Cedar Rapids, IA, launched a cross-continuum heart failure program, the rate of readmissions for heart failure patients dropped from nearly 30% to just 17%.
The program includes development of consistent educational materials used across the continuum of care, timely physician visits for follow-up care, and a home health visit within two days of discharge from the hospital for every patient with heart failure.
The hospital developed a heart failure team in 2001 to look at ways to reduce readmissions, but outcomes really improved when the hospital participated in the Institute for Healthcare Improvement's series on the Ideal Transition to Home, reports Peg Bradke, RN, MA, St. Luke's heart care services director.
"We learned that the heart failure team we were working with was just a hospital team and we weren't looking beyond the hospital walls at the big picture," Bradke says.
The original team included Bradke, representatives from social work, the cardiac step-down unit, the emergency department, the medical unit, and care coordination.
After the kick-off meeting with the Institute for Healthcare Improvement, the hospital representatives expanded the existing heart failure team to include clinicians and family members who provide care for patients after discharge. Among the additional team members are the director of nursing from a long-term care facility, representatives from home health agencies, a nurse from a physician practice specializing in cardiology, and the daughter of a patient who was a Stage 4 heart failure patient.
"Before we expanded the team, we had been rationalizing that the majority of our readmissions were Stage 4 heart failure and we couldn't impact that. By working with the cross-continuum team, we determined that there were things we could do to help the high-risk patients avoid readmissions," Bradke says.
One of the keys to the success of the initiative is arranging a home health visit for every patient who is discharged with a diagnosis of heart failure. All patients with a primary diagnosis of heart failure are enrolled in the program and receive a follow-up home visit, if they agree. Then, the heart failure nurse calls all patients seven days after discharge to find out how they are doing and to answer any questions or concerns.
The team looked at how many patients did not qualify for home care services but could benefit from a home care visit and found that many patients covered by Medicare did not qualify because they were not homebound.
"We felt that we were missing an educational opportunity with these patients. We asked our hospital administration if the hospital could support one follow-up visit by a home health nurse for patients whose insurance didn't cover home health services," she says.
Now, the care coordinators schedule a home visit 24 to 48 hours after the patient is discharged.
If patients qualify for home care, the hospital gives them a list of agencies to choose from in order to meet the Medicare conditions of participation. If they aren't covered for home care, the hospital sends out the home care agency it contracts with.
During the home care visit, the nurse looks at what foods are in the kitchen and educates the patients on which foods are high in sodium and should be avoided. She takes the patients' blood pressure and pulse and does a safety check of the home.
"We think the home visits are a major part of helping patients adhere to their treatment plan. We've found that the best place for medication reconciliation is in the patient's home when they can pull out the shoe box with all their medication in it. The home care staff have found quite a few duplicate medications or learned that patients have not been taking their medication properly," she says.
The hospital has always scheduled follow-up appointments before patients are discharged, but it took a lot of work to convince the attending physician that two to three weeks wasn't soon enough for a visit, Bradke says.
The hospital team members compiled data on readmissions to demonstrate to the physicians what a difference it would make if they saw the patients sooner.
Now, about 80% of patients get in to see a physician within seven days, compared to about 10% to 12% when the initiative started.
"The cardiologists had been taught to automatically set a follow-up appointment in two to three weeks. We worked with them to create a standing order to change the follow-up appointment date if necessary to make sure the patient sees the cardiologist in the first week," she says.
When the initiative began, the team examined the education process and educational materials used by all of the disciplines throughout the continuum of care.
"It was evident from our review of the materials that every person who educated the patients did something different. The information patients got in the hospital wasn't the same as what the home care staff gave them and could be different from the information they received in the clinic," she says.
The cross-continuum team began working on developing educational materials in February 2006, and over the next nine months had the materials reviewed by patients and family members, then tweaked them based on patient and family suggestions.
The family member participant on the heart failure team shared the materials with her siblings. The team presented the materials to several sessions of the hospital's outpatient heart failure class to find out if they understand the materials and to get their input.
"As a system, we were doing a lot of education on health literacy and beginning to implement patient- and family-centered care. We incorporated this into our heart failure education initiative," she says.
"What has made this initiative so different is that we are listening to the voices of the patients and the family members. We wanted to tailor the program to do what is best for the patient, and the best way to do that is to get their input on what will make a difference," she adds.
The team worked on consistent education and created a simple and easy-to-understand packet of information to replace the piles of paper patients had been receiving.
The team designed a 5 x 7-inch refrigerator magnet with the warning signs and symptoms of heart failure that should be reported to the physician.
"Our patient educational materials have been redesigned to include only the essential information. We give patients a magnet and a one-page sheet that describes the pathology and physiology of heart failure in words they can understand," she says.
The hospital calls its nutritional hand-out an "Eating Plan" rather than a diet plan. The document is written in simple language, with lots of pictures.
"When the representatives from the long-term care facility and skilled facilities reviewed the packet of information, they reported that they would find our educational information useful in treating the patients we refer to them," she says.
The representatives from the post-acute facilities asked for the magnets to hang in patient rooms above the scales to continue the educational process as the patient was being treated.
"We found that it's the little things, like the magnet, that make a big difference," she says.
The cross-continuum team incorporated the teach-back method into the patient care delivery at all levels of care.
"Teach back" means asking patients to repeat in their own words what you have just taught them to make sure they completely understand it.
The team came up with four teach-back questions that staff in the hospital, the clinic, and home care all use in their patient education:
The hospital has published a calendar for heart failure patients with spaces for the patients to log their weight each day, health tips for each month, and times and dates of the hospital's heart failure classes.
"The calendars are very popular. Patients who haven't been in the hospital for a while call and ask for them," she says.
The hospital's cardiac rehabilitation nurse and dietician have presented heart failure classes to the staff at nursing homes and long-term care facilities.
"The staff in these facilities are generalists, and they can't keep up with everything. The facilities welcomed us and sent their nurses, their certified nurse assistants, and even their dieticians to the classes," Bradke says.
The hospital also offered the classes to all the home care agencies in the area.
The team has developed a new transfer form for patients going to long-term and skilled nursing facilities. In addition, the care coordinators make a verbal report to their counterparts at the facility to emphasize patient care needs.
The team continues to meet regularly to analyze readmissions and look for things that could have been done differently to prevent the patient coming back.
"In the hospital, we look at the information that we are getting upfront from the patients. If they are readmitted, we ask patients in their own words what brought them back, compare it to what the doctor says, and incorporate that into our education," she says.
When the initiative started, the team met weekly, then cut back to every two weeks , then monthly.
Now, the team is meeting every two weeks and looking at coordination of care throughout the continuum for patients with chronic obstructive pulmonary disease and pneumonia.
The hospital added family members, a respiratory therapist, and a nurse from a pulmonologist clinic to this team.
Building relationships with post-acute providers is a good way to improve patient care throughout the continuum, Bradke says.
In the past, she called long-term care facilities to ask how the handoffs from the hospital were working.
"We got glowing reviews. After all, we're their customer and they weren't likely to tell me any complaints over the phone when they didn't know me. Now that we've built that relationship, it's easier for them to call us when we have a poor handoff. Then we can work together to make it better," she says.
(For more information, contact: Peg Bradke, RN, MA, heart care services director, St. Luke's Hospital, e-mail: BradkeMM@ihs.org.)