Telephonic program cuts CHF readmissions in half

Nurses follow up after discharge 

A post-discharge follow-up program for congestive heart failure (CHF) patients has decreased the readmission rate by more than half at Harper University Hospital in Detroit.

Nurse case managers specially trained to do triage assessment by telephone follow up with the CHF patients after discharge, making sure patients monitor their weight and blood pressure on a daily basis and reinforcing the patient education instructions patients received during their hospital stay.

"The results have been quite dramatic and quite beneficial for the patients," says Joseph Bander, MD, the hospital’s vice president for medical affairs. It’s one good example of how hospitals can provide good quality care at less expense."

The hospital started its CHF program two years ago.

The patients are enrolled in the program while they are in the hospital. After discharge, three nurses dedicated to the program call the patients twice a week for the first month and follow up at less frequent intervals for as long as six months, educating the patients for signs and symptoms to watch for in the course of their disease.

Depending on the symptoms, the patients are either managed by the nurses over the telephone or urged to see their physician.

"If patients can be identified if they are getting in trouble much earlier in the course of the disease, they don’t need as much intervention. Their quality of life is better, the expense of care is diminished, the burden on the third-party payer is diminished, and the patients get better care," Bander adds.

In addition, the telephone calls give some of the patients some social contact that they might not otherwise have had, he adds. "They are aware that we care about them."

The hospital created a separate staff, rather than use the hands-on nursing staff, to make the telephone calls. "For us, it makes sense in terms of better care, and since readmissions are not reimbursed by Medicare within a certain time frame, it makes financial sense to dedicate staff to work with the patients to prevent costly readmissions," Bender explains. The hospital is developing similar programs for diabetes, hypertension, and other diagnoses, he adds.

CHF is Harper University Hospital’s highest volume admission and one that has a high mortality rate for patients over time, Bander points out.

"Once a patient starts to develop congestive heart failure, there is a marked increase in mortality, and perhaps their lives are shortened unnecessarily. The program has given us better financial outcomes and better quality of care for the patients. It’s a win-win situation," he says.

CHF is a diagnosis for which there are frequent readmissions, Bander notes. "It’s a diagnosis that requires a lot of patient education and follow-up on a regular basis. A busy physician simply cannot follow up in the way that is needed. That’s why we committed our nursing personnel to do so."

The nurses selected to make the outbound calls are highly experienced and undergo a lengthy training process to learn to assess patients over the telephone. "Telephone assessment is very different from bedside assessment. Hands-on nursing requires a different skill set," he says.

The nurses have a checklist of items to cover when they call the patients, including daily weight, blood pressure, and dietary questions.

As patients are enrolled in the program, the hospital provides them with an automatic blood pressure cuff and a scale to make sure they can measure their daily weight and blood pressure.

The hospital has developed very explicit discharge instructions for CHF programs. Patients can call a nursing line 24 hours a day, seven days a week.

The three CHF nurse case managers answer the telephone during their working hours. The line is covered by other staff after hours.

While the patients are in the hospital, specially selected clinical resource management nurses review each chart to make sure the care is consistent and follow the hospital’s best practice guidelines for CHF and other targeted diagnoses.

"Our goal is to assure that patients who meet appropriate criteria receive appropriate, nationally recognized medical interventions," he says.

As third-party payers are requiring more detailed documentation, physicians face an exceptional load of paperwork and may not include as many details as necessary.

That’s where the clinical resource managers come in, Bander explains.

"We have committed ourselves to making sure that nobody falls through the cracks. Sometimes, things can be overlooked, and it helps to have somebody following along to make sure that it’s not," he notes.

If the chart doesn’t indicate that the patients have received the recommended care, the clinical resource managers get in touch with the physician to find out if there is a reason why and ask them to provide the appropriate documentation.

"It’s important for reimbursement and for anyone else who comes along and tries to understand what is going on in the chart," Bander adds.