Here’s how education saved $173,000

Careful measurement guides plan

When Columbia San Jose (CA) Medical Center (CSJMC) initiated its study to see if a structured education program for patients with congestive heart failure (CHF) could reduce readmission rates and save money, the study team saw that educational intervention cut readmission rates in half, and net savings to the hospital was nearly $173,000.

The intervention group’s post-test responses revealed the education they received spurred significant improvements in how much they knew about their disease and how well they could handle self-management. (See graphs illustrating these points, p. 146.)

The four areas improved were as follows:

• diet awareness and eating behavior;

• medication compliance;

• weight monitoring;

• confidence.

CSJMC’s project involved a core team con-sisting of 10 people, including nurses, patient educators, quality improvement staff, a pharmacist, a hospital librarian, and a representative from Krames Communications, a publisher of consumer-oriented wellness and safety materials in San Bruno, CA.

The team randomly assigned patients with a discharge diagnosis of CHF to intervention or control groups. Excluded were those with end-stage disease and those who would have difficulty with English-language educational items. Nurses interviewed all study participants within 14 days of discharge to gather pretest baseline data. They measured how much participants knew about CHF and how aware they were of lifestyle skills for managing their condition. A post-test 12 weeks later measured changes in knowledge, self-management behavior, and confidence.

Initial assessments of control and intervention groups revealed that most patients learn little about CHF and how to manage their disease during their hospital stay. Regarding diet, only 63% knew that what they eat is important, as well as the following factors:

• only 49% knew to limit salt;

• 53% hadn’t weighed themselves for a minimum of two days;

• 79% weren’t sure when to call the doctor if they gained weight;

• only 42% knew the importance of medication compliance;

• 30% had forgotten to take medication in the preceding three months;

• 37% lacked confidence in their self-management abilities;

• 36% rated their health as poor.

"There’s no doubt CHF patients need to be educated," says Jackie Torpy, RN, BSN, coordinator of the Alegent Health Heart Institute’s Heart Failure Center at Immanuel Medical Center in Omaha, NE. "The more educated they are, the more compliant they are. Patients have no idea what heart failure is when they first come in. They only register ‘heart attack,’ and CHF is different. Patients are versed on what they’ve heard about fat, triglycerides, and cholesterol — which is not to say they shouldn’t be — but CHF has to do also with sodium and fluids, and they have difficulty dealing with that."

"Educating patients involves more than putting information in the mail. Intervention needs to be behaviorally staged," explains Seth Serxner, PhD, director of research at Krames Communi-cations. Those stages are awareness, skill building, and maintenance.

Nurses typically are effective at teaching patients about their disease, and they’re also adept at building skills such as injecting insulin and demonstrating the peak flow meter.

"It’s at the maintenance phase that we fall down," he says. Medication compliance, dietary compliance, and monitoring early warning signs come under the category of maintenance, and it’s those behaviors that need to be reinforced. The focus of the intervention in the CSJMC study was maintaining and reinforcing long-term health behaviors.

The intervention ran for 12 weeks. "To keep patients’ attention, you have to contact them on a regular basis. A direct sequence mailing does that," Serxner says. Four education packets were delivered by mail, each with a personal letter from the quality improvement group director. The format of each packet varied, because, he says, "If you get materials that look the same, you tend to chuck them out. If every time a package arrives, its shape and color are different, you’re curious and pay attention."

The cover letter costs practically nothing, explains Monica Miyaji, RN, quality improvement coordinator at CSJMC, yet it is perhaps the most important piece in the mailing. Each is addressed personally and signed by a doctor. The body of the letter describes the materials included with the package. It invites questions by including a contact name and phone number and reinforces the key points of the materials. For example, it might say, "Keep in mind that weighing yourself each day is very important. Remember to take your medications."

The personalized accordion-pleated folder in the first mailing seemed to make a difference in how patients viewed the information being sent to them. "It really works," says Miyaji, "When we called patients, they’d say, ‘Oh yeah, let me get my folder.’ The folder made it clear that each piece is in the context of an overall program."