Critical Path Network

Outreach program reduces readmissions for HF

Nurse visits high-risk patients in home

Readmissions among all heart failure patients dropped by 50% in the first year of Saddleback Memorial Medical Center's comprehensive heart failure program, which focuses on a smooth transition between the hospital and the community.

Patients in the program also show significant improvement on the Dartmouth Quality of Life Index, says Louise Della Bella, RN, MN, CNS, NEA-BC, executive director for care management, discharge planning, and social services.

"We use this index to determine if the patients are improving subjectively as well as objectively. We not only are keeping them healthier, we are improving their quality of life," she adds.

A key component of the program is the addition of a heart failure outreach coordinator who visits high-risk patients in their homes and works with their physicians to help the patients learn to keep their condition under control. The outreach program is funded by the hospital foundation.

"Heart failure is one of the major diagnoses for readmission to the hospital. We know that patients with heart failure are readmitted for a variety of reasons. We wanted to make sure we follow best practices while the patients are in the hospital, that we discharge the patients at an appropriate time, and that we follow up after discharge," says Della Bella.

Following the initial success of the program, the hospital has begun a pilot study using remote telemonitoring equipment.

"We hope that by using technology, we can reduce readmissions even more while freeing up the outreach coordinator's time to work with the patients who need it most," Della Bella says.

Patients in the pilot project use a Bluetooth-enabled wireless remote monitoring system that collects the patients' weight and other bio-metric data and transmits them to Saddleback's health information group of nurses, who monitor the data and either alert the patient's physician or Laurie Carson, FNP-C, MSN, heart failure outreach care coordinator, when there is an increase in body weight or other problems that could indicate an exacerbation.

"By taking a proactive approach, we can intervene before the patient's symptoms become severe enough to warrant hospitalization," Della Bella says.

A multidisciplinary team at the hospital identified the reasons heart failure patients are readmitted, including medication issues, excessive salt intake, and weight management problems, and developed a plan that begins with beefed-up education at the bedside.

"We make sure the patients understand the importance of following their treatment plan when they're in the hospital, and we recognize that patients go through a very difficult period when they get home. We make sure that those who are at highest risk for an exacerbation get a home visit as soon as possible after discharge," she says.

The care of the sickest of the sick patients — those with stage 4 heart failure — is coordinated by Carson, an advance practice nurse with years of experience in heart failure, who also worked with the hospital team to design the program.

About 95 patients have participated in the home visit program since it started in 2007.

"These are the patients who are at high risk for readmission and who are likely to have a really difficult time if they have a readmission. They are the patients who will have a high financial impact on the hospital," she says.

When patients in the program do come back to the hospital, their consumption of resources is lower than patients who are not in the program, Della Bella says.

The program currently is limited to Medicare patients.

"Most managed care plans have disease management programs for heart failure patients. The programs are telephonic and don't provide the face-to-face assistance that we do; but these patients do have some support," Della Bella says.

When the heart failure case manager on the unit identifies a patient who is eligible for the home visits, she alerts Carson, who visits the patient before he or she leaves the hospital and works with the heart failure case manager to ensure that the patient has a smooth transition back home.

"The program is all about coordinating care for patients throughout the continuum of care, rather than just treating isolated events for the patient," she says.

The heart failure case manager on the unit starts the process of educating the patients about what they should do after discharge. She is responsible for the core measures and works with the nursing staff and the physicians to ensure a coordinated hand-off to Carson.

Before the patient is discharged, the hospital sends an introductory letter to the patient's physician, describing the program and asking for the doctor's approval for the patient to participate.

"The doctors have been extremely happy with the program. It reduces their phone calls and helps their patient manage better at home," she says.

Carson works with each patient's physician, usually a cardiologist, to develop processes of care.

"This program is a true collaboration between levels of care and clinicians. We aren't doing it in isolation. We want the physicians to know what is going on with their patients because it helps the patients keep their condition under control and enjoy a better quality of life," she says.

On her first visit, Carson completes a comprehensive physical assessment, goes over the information the patient received in the hospital, answers questions and concerns, and does a home assessment.

"We tailor our program to meet the patient's needs. The focus is on making the patient as independent as they can be in their care. We set goals and make sure that the patient and family members understand what we want to do," Della Bella says.

Depending on acuity, Carson may visit the patient in his or her home several times a week or as little as once a week to start.

"It's strictly dependent on the patient's condition. If they have a bad week, she may increase the visits. If they are managing independently, her visits are less frequent," Della Bella says.

The program focuses on making heart failure patients more independent.

"We don't want to do for the patients. We want them to learn to do for themselves. We teach them what they can and cannot do, what symptoms indicate they should call their doctor, and what they should do to follow their treatment plan," she says.

For instance, Carson teaches patients when they should call their physician and helps them ask the right questions of their physicians but encourages them to make the telephone calls themselves.

She enters information on each patient in the electronic record so that when the patient comes back to the emergency department or is readmitted, the treatment team will have information on what happened when the patient was at home.

"Saddleback has a reputation for being the most high-tech hospital in Orange County. We are using our electronic medical record to help with the communication piece across the continuum of care," Della Bella says.

When patients are discharged with home health services, Carson collaborates with the home health nurse to ensure a smooth transition from home health to the heart failure program. She works with representatives from palliative care and hospice when patients decide they are ready for those services.

"Some patients don't want further treatment. They just want to be comfortable and pain-free. With this program, the nurse practitioner is able to initiate those conversations in the home and make sure the patient's wishes are followed," she says.

(For more information, contact:

Louise Della Bella, RN, MN, CNS, NEA-BC, executive director for care management, discharge planning, and social services, Saddleback Memorial Hospital, e-mail: