Coordinate open heart care with hospital

Hospital home health agency has 4-visit pathway

Hospital home health agencies are perfectly situated to provide new, post-surgery services as hospitals cut back on post-op lengths of stay. These home visits provide patients with a continuum of care that is cost-effective and prevent infections and unnecessary hospital readmissions.

Elkhart (IN) General Hospital launched an open heart surgery program in January 1997 that includes four post-surgery home health visits. Outcome data are not yet available, but so far anecdotal evidence suggests the program is accomplishing its goals on both the home health and hospital side, say key personnel involved with the program.

The hospital provides the full circle of cardiac needs, including angioplasty and open heart surgery. The chief goal of the home health segment of the pathway is to prevent patients from returning to the hospital and to prepare them for outpatient rehabilitation. Elkhart General Home Care has accomplished these goals, says Cindy Bieber, RN, CCRN, cardiac rehab coordinator for the 350-bed hospital, which serves a northern Indiana community.

Home care nurses find complications and other problems before they become too serious, notes Bieber. In addition, home health staff provide patients with emotional support and reinforce patient teaching on medications, nutrition, and exercise, she adds.

"It makes a significant and measurable difference," Bieber says. "I know from my own home health experience that if you weren't there to find a problem with post-open-heart surgery patients, the patients might not have called a physician until they were at death's door."

The home health visits also increase patient satisfaction and provide positive public relations for the hospital, says Shelby Morse, RN, hospital director of case management.

"Patients really appreciate having a nurse visit them and having someone who can answer questions and help them feel confident about their recovery," Morse says.

Here's how the hospital and home care agency set up the program:

1. Assess need.

Elkhart has had an intensive coronary care unit, but for years the hospital only provided medical treatment for cardiac patients. "We used to transfer out any invasive cardiac procedures," says Susan Stack, RN, CCRN, coordinator of open heart recovery.

Then physicians and hospital administrators analyzed some patient data and realized they were sending a lot of patients to the South Bend-area and Indianapolis for angioplasty and open heart surgery, Stack adds. "Once they got the statistics, they realized this area would benefit from a heart program," Stack says.

2. Create pathway.

The hospital and cardiac care team developed a clinical pathway that tracks patients from surgery to recovery, post-op care to home health, and then to outpatient cardiac rehabilitation.

One pathway was established for all patients, regardless of payer source, Morse says. "We wanted to offer the same standard of care to anyone who was eligible, so our decision was to develop a full-visit pathway."

The home care pathway includes four visits. The visits are as follows:

- Visit One. This lasts about an hour and takes place within 24 hours of discharge from the hospital. The home health nurse assesses the patient's condition, including observing the chest and leg incisions, looking for signs of nausea and infection. Then the nurse reinforces instructions the patient was given in the hospital, says Judy Rayhill, RN, former staff development coordinator for Elkhart General Home Care. Rayhill now is the nursing coordinator for health care personnel.

Home health nurses also discuss medication, signs and symptoms of infection, and fluid restrictions. They tell patients to check their temperatures and pulses regularly and record their findings. Patients are taught to keep a daily log listing the type and duration of their exercises, Rayhill says.

- Visit Two. This visit occurs on the third day after hospital discharge. Nurses review the patient's exercise log and temperature log to make sure they are recording information correctly. Nurses also make sure patients are taking their medications correctly and have no difficulty tolerating medications. "We also make sure their appetites are getting better and not worse," Rayhill says.

- Visit Three. This visit takes place on the seventh day after discharge. Nurses reinforce patient education by discussing the disease process and the importance of exercise, good nutrition, and proper hydration, Rayhill says.

- Visit Four. Nurses make the fourth visit after the patient has visited the physician's office. It takes place typically on the 10th or 14th day after hospital discharge. Prior to this visit, the home care agency sends the physician information about the patient's progress. If the physician recommends any changes, the home health nurse makes these adjustments at the fourth visit, Rayhill says.

"We make sure the patients have all the information they need before they start cardiac rehabilitation," Rayhill says.

3. Develop patient teaching tools.

Hospital and home health staff use one pathway, and patients are given another that covers three weeks of care, starting when the patients are first hospitalized. The 15-page patient pathway includes all of the educational material they might need to understand their disease and its treatment.

Bieber says she created the patient pathway partly to help patients with their anxiety about what will happen next and what is expected of them. "It also offers encouragement throughout the pathway," Bieber says. "For instance, on Day Four, it states,'Keep up the good work; walking makes you stronger and helps the healing.'"

The first page of the patient pathway explains why the patient is in the hospital and what will happen during each step of the surgery and recovery.

"Also, before they go home from the hospital, we give them an activity work sheet," Bieber says. The work sheet includes information about how much walking patients should do each day and how to watch for symptoms of infection or other problems. It includes a place for patients to log their heart rate.

4. Convince payers of program's merits.

Home health care for the open heart surgery patients is necessary for the patients to be given a continuum of care, Morse says. Insurers usually understand this and are willing to pay for the home health visits, she notes. "Most of the commercial companies have been receptive to this because they believe it will help with good outcomes."

Once the hospital and home health agency have outcomes data available, it could help in convincing payers to cover the home health segment.

Physicians also are pleased knowing that their patients will be seen by nurses in that two-week period after they are discharged and before they return to the doctor's office, Morse says.

In addition, most of the Medicare patients meet the homebound requirements for home health care, and Medicare pays for the post-op home health visits. However, even if an insurer agrees to pay for only two visits, the hospital provides three or four home health visits, Morse says. "We make those home visits to accomplish the goals that are part of the pathway."