Free heart failure clinic aims to cut readmissions
Targeted patients often have limited funds
When Mountain States Health Alliance determined that a third of its heart failure patients were readmitted within 30 days of discharge, the Johnson City, TN, health system opened a free heart failure clinic at its flagship hospital, Johnson City Medical Center.
When the hospital analyzed heart failure readmissions, the team determined that one reason patients were being readmitted within 30 days of discharge was that they couldn't get a follow-up appointment with a primary care provider within seven days, says Genia Lauro, RN, director of cardiovascular services. There were also socioeconomic reasons that patients needed to be readmitted. Many of them couldn't afford their medication and didn't get their prescriptions filled, she adds.
Patients with limited funds and no insurance often don't have a primary care provider and don't go to the doctor for follow-up visits because they can't afford it, says Julia Bates, NP, the nurse practitioner who runs the outpatient heart failure clinic. In addition, if patients don't have the money to pay for their medication or don't take it as directed, they end up back in the hospital, she adds.
"When we look at the total picture, by offering the free clinic and avoiding readmissions, we are saving the hospital money. One admission costs thousands of dollars. In addition, we are improving patients' quality of life by helping them learn to manage their disease so they don't need to be hospitalized," Lauro says.
The clinic opened in August 2012 in a space in the hospital. "It's a convenient location and the patients know where to find it," Bates says.
Most of the patients are referred to the clinic when they are still in the hospital. "I try to see all the heart failure patients when they are in the hospital to find out how much they understand. The goal is for me to see all patients in the clinic at least once," Bates says.
A nurse also makes follow-up calls to heart failure patients within 72 hours of discharge to make sure they have filled their medication, to go over their discharge instructions, and make sure they have a follow-up appointment in the clinic.
Bates gives the patients her telephone number when she visits them in the hospital and encourages them to call with questions. Some patients call her with questions before their first visit to the clinic.
"Patients receive education at discharge, but many times, they just want to go home and don't listen. Then when they get home they have questions or their family members have questions," Bates says.
The hospital also encourages patients to walk in to the clinic any time, even before their appointment, if they are having problems. "We want them to come to the clinic before their condition deteriorates to the point that they go to the emergency department and/or are admitted," Lauro says.
When patients come to the clinic, Bates conducts an assessment to find out how much they understand about heart failure and how to manage it and if they have social and financial issues. She helps patients who need it sign up for medication assistance and starts educating them on how to manage their disease and what signs and symptoms indicate that they should call their physician or come to the emergency department.
"Heart failure is not going away. It only gets worse. Patients who are in Stage 3 or 4 don't have a good quality of life. We want to help them understand what they need to do to stay active and in good health as long as possible," Bates says.
Often it takes multiple repetitions for patients to fully understand their treatment plan, Bates says. "Continuing education and continuing support is very important. They still want to be normal and eat what they want. Having someone they can call for encouragement or to answer questions is very important," she adds.
She encourages patients to call her whenever they have questions or concerns. "I get a lot of telephone calls on Friday because people are worried about the weekend and don't want to have to go to the emergency department," she says.
Following a heart failure diet may be the biggest challenge for many people, Bates says.
"I try to teach them how to be smart about what they eat and read labels. If they really like a food that they shouldn't eat, they know to cut down on the portions and balance it with other foods. It often takes six or more appointments before they understand, but I have patients in their 80s who know how to balance their diet," she says.
Whenever possible, Bates includes family members in the educational sessions.
"How well people do often depends on the family. They need to understand heart failure, what signs and symptoms indicate problems, and the challenges that the patients face. Whoever is cooking for the patients need to understand the importance of a low-sodium diet," she says.
Bates gets a daily report of heart failure patients who have been admitted. If they are readmitted, she visits them and collaborates with the patients and the hospital social worker to come up with a plan to avoid another readmission. "We do everything possible to give them a chance but we still have patients who die because of non-compliance. One heart failure patient was just 39 years old when he died, but despite everything we tried, he continued to smoke and drink alcohol," she says.
Bates also presents classes at the Health Resource Centers in Johnson City and Kingsport, TN. "Our community has a large population with heart failure. We want to teach them how to take care of themselves so they will do well and stay out of the hospital," she says.
The patients who come to their appointments and follow their treatment plan do very well, Bates says.
"I have patients who were in here every month and now I don't see them for six months. But if they don't show up for their appointments and don't take care of themselves, they end up in the hospital," she says.