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Systemwide HF program decreases readmissions
Collaboration among all levels of care key to success
A systemwide initiative that coordinates care across the continuum for heart failure patients has reduced the 30-day readmission rate for the North Shore-LIJ health system.
"Heart failure is a chronic condition that affects about 6,000 patients in our system every year. Coordinating care for this chronic condition is imperative to reduce avoidable readmissions," says Karen Nelson, RN, vice president of clinical excellence and quality for the metropolitan New York City health system.
The health system has created a three-year strategic plan for clinical excellence and quality that is aligned with the National Quality Forum's national priorities. One area of focus is reducing 30-day readmissions for patients with heart failure.
The strategic plan "began to clearly articulate the quality imperatives, actionable initiatives, and measures of success for the health system," Nelson says.
The health system was presented the National Quality Forum Healthcare Award for its ongoing commitment to providing high-quality, transparent, and patient-centered health care.
The heart failure process redesign was undertaken by a task force made up of representatives from 14 hospitals, two long-term care facilities, five home health care agencies, ambulatory care, and the health system's hospice network.
"A strong emphasis was placed on transitioning patients to the next level of care and enhancing information flow among care providers, patients, and their families/caregivers," Nelson says.
The task force includes full-time and voluntary community physicians, nurse practitioners, nurses, social workers, case managers, nutritionists, representatives from quality management, administration, pharmacy, and procurement as well as representatives from the health system's hospice, subacute and long-term care facilities, and home care agencies.
"The heart failure program was prioritized by clinical and administrative leadership throughout the organization," Nelson says.
A physician and a nurse co-chair the task force.
"The first objective was to agree on best practices as identified in evidence-based research and to explore successful initiatives in other institutions," says Geraldine Koster, RN, director of operations for the institute of clinical excellence and quality.
The task force identified four distinct phases of care and established subcommittees for each phase: emergency department, inpatient, discharge, and post-acute.
The subcommittees developed flow charts and diagrams to help identify barriers to effective and efficient care delivery and opportunities to enhance care coordination and communication handoffs.
"We challenged the clinicians on the subcommittees to come up with specific ideas to improve communication among the phases of care and to report back to the task force. There was a lot of discussion and consensus building during the process," she says.
The task force used the suggestions from the subcommittees to develop tools that bridge gaps in care and ensure consistency throughout the treatment process and throughout the health system.
The team developed tools such as diagnostic and treatment algorithms, admission order sets, and a discharge pathway, all of which incorporate evidence-based care. The team developed patient and family teaching materials that are used consistently throughout the organization. Since English is not the primary language for many patients, the educational materials were translated into multiple languages.
The heart failure tool box and evidence-based care delivery are standardized systemwide, but the individual facilities determine how they will implement them, Nelson adds.
For instance, some hospitals have designated heart failure nurse practitioners or other mid-level providers to coordinate the care of heart failure patients. Others use case managers, clinical care coordinators, and discharge planners in the care coordination role.
The heart failure task force continues to meet once a month using data to review performance and shares best practices and lessons learned across the health system.
"When we started this process, everyone agreed that the program would be initiated and modified as needed after implementation throughout the system. Any part of the process that was working as expected would be revisited," Nelson says.
The heart failure program starts in the emergency department where the team identified variations in treatment, Koster says.
The emergency department staff were educated on the evidence-based treatment for heart failure, and the task force subcommittee developed an algorithm for treating heart failure.
"It's an ongoing process. Hospitals have established concurrent monitoring to ensure that the algorithm is being followed," Koster adds.
Multidisciplinary heart failure teams at each site conduct rounds on heart failure patients to ensure compliance with evidence-based care.
The clinical team works with the patients and their caregivers to develop a plan of care that takes into account the severity of the patient's condition, support from family members, and other psychosocial issues.
All patient information including the plan of care, dietary requirements, and medication is available to providers at every level of care through the health system's electronic system, Nelson says.
A key to the success of the initiative is multidisciplinary rounds at each hospital, which may include, but are not limited to, physicians, nurse practitioners, physician assistants, nurses, case managers, and social workers; the mix can vary depending on the hospital.
Part of the challenge is that heart failure patients are not always in the same unit. The attending physician may be a cardiologist, a hospitalist, or an internist.
"This is why the team approach and rounding is so important," Nelson says.
The discharge planners begin the discharge process when the patient is admitted. They conduct an assessment of the patient's needs for support after discharge and when, appropriate, make a referral for home care services within 24 to 48 hours of admission.
Clinicians from each hospital in the system make post-discharge telephone calls to heart failure patients 24 to 48 hours after discharge and make weekly follow-up telephone calls for six weeks.
The person making the follow-up phone calls varies from site to site, depending on the resources at each facility, but the calls always are made by a clinician. In some hospitals, the case managers make the calls. One hospital uses the post-anesthesia care unit nurses to make follow-up calls early in the day, Nelson says.
During the weekly phone calls, the clinicians assess the patient's progress, ask about diet, weight, and medication compliance, and educate the patient when needed.
"We found that many times, patients are confused about their medication once they get home. Even though they received discharge instructions in the hospital, they go home to a cabinet full of medications and are not clear as to which medications they should be taking," Koster adds.
Several patients have been identified as having early signs of exacerbation of their condition during the post-discharge telephone call.
Case managers and other clinicians have been able to identify patients who are short of breath or have gained weight and have instructed them to contact their physician.
At present, the clinicians make phone calls only to patients who have been discharged to home.
"Expanding the calls to include patients discharged to another facility is an opportunity for the future and will require facilitation on a facility-by-facility basis," Nelson says.
The teamwork has facilitated direct communication between the discharge planners and home care services, Koster says.
"When we discharge our patients to North Shore-LIJ home care and subacute or long-term care facilities, we have enhanced communication because we have worked together on this initiative," she adds.
"Hospitals have reached out to their local nursing homes and subacute facilities to foster relationships, provide education, and enhance communication transfer with the goal of improving care and working together to reduce heart failure readmissions," Nelson adds.
Depending on the wishes of the receiving organization, the discharge planner provides written information or telephones the next provider with patient information.
The heart failure team developed a universal teaching booklet that is being used across the entire continuum, Koster says.
The "Be in the Know" pocket guide to heart failure includes signs and symptoms patients should look for and when they should contact their physician.
"We are sending a consistent message and giving the patients materials they can recognize. They receive the same booklet and instructions whether they're in the outpatient setting or being discharged from the acute care hospital," she says.
In addition, the hospitals give scales to patients who do not have one and encourage them to weigh themselves every day and to call their doctor when they experience unusual weight gain.
The team tracks readmissions and analyzes the data to determine if any processes need to be refined.
For instance, at one site, if a patient is readmitted and was under the care of the North Shore-LIJ home care, the nurse at the hospital and the home care nurse are in direct contact to assist in determining what might have lead up to the readmission and to address opportunities for improvement in the future.
"If a patient is readmitted within 30 days, it triggers an extensive readmission review to identify further opportunities to improve the process," Nelson says.
The systemwide 30-day readmission rate for heart failure has gone from 24.9% in 2009 to 19.8% in 2010.
"This downward trend is very encouraging. However, the heart failure program requires constant vigilance and teamwork to continue to achieve success," Koster says.