Initiative leads to 11% drop in HF readmissions

Coordinators follow up after discharge

After the University of California San Francisco Medical Center began a heart failure readmission reduction program at its 559-bed main hospital, 30-day readmission rates for heart failure patients dropped 46%, from 24% in 2009 to 13% in 2011 and 11% in 2012.

The 559-bed hospital started its heart failure initiative, focusing on patients 65 and over, in 2008 with a two-year grant from the Gordon and Betty Moore Foundation and training from the Institute for Healthcare Improvement. The hospital has continued the program on an ongoing basis and expanded to include all heart failure patients 18 and older.

“We knew that heart failure was the No. 1 reason older adults are readmitted to the hospital. When we started the program, nearly 1 in 4 heart failure patients were readmitted. We knew that we had to do something different to improve patient care and keep these patients safe at home,” says Eileen Brinker, RN, MSN, heart failure program coordinator.

The heart failure team includes two nurses, Brinker and Maureen Carroll, RN, CHFN, who work together on a part-time basis (1.6 FTEs) to coordinate the program. They are supported by a multidisciplinary team including hospitalists, cardiologists, clinical nurse specialists, case managers, social workers, pharmacists, dieticians, and chaplains. In addition, they coordinate care with primary care physicians, skilled nursing facility staff, home care nurses, and outpatient nurse practitioners in the health system’s heart failure clinic.

Brinker and Carroll worked with the multidisciplinary team to analyze the hospital’s care processes and identify opportunities for improvement.

“When we analyzed the situation, we saw a lot of gaps in care. Patients were being treated in silos—the hospital, the clinic, post-acute facilities—and there wasn’t a cohesive treatment plan or a smooth transition between levels of care. Sometimes patients were being treated in the clinic across the street, but those providers were not aware that their patients had been in the hospital,” Brinker says.

During the first year of the program, the multidisciplinary team concentrated on the inpatient experience, particularly education for patients and family members, using the teach-back method.

The team revised educational materials, taking healthcare literacy issues into account, and got feedback from cardiologists and the program’s Patient Advisory Council. They developed a comprehensive binder of heart failure educational materials, including adopting the Heart Failure Zones chart to show patients what to do in case of symptoms and including information on low-sodium diets from the dietician. “We adopted materials from a number of sources, rather than reinventing the wheel. We have modified the information along the way based on input from patients and family caregivers,” Brinker says.

The hospital also translated the materials into Chinese, Russian, and Spanish. “We use an interpreter when patients are in the hospital, but we wanted them to have something to refer to when they go home,” she says.

When patients are admitted with heart failure, the coordinators meet with them to provide education and post-acute needs. They request appropriate consultations for case management, social work, dietary, or palliative care and determine post-discharge needs, including rehabilitation and home health care. The nurses focus on patients with a primary diagnosis of heart failure and see patients with a secondary diagnosis as time permits.

The heart failure nurse coordinators spend about 15 to 20 minutes with each patient every day. “We build on the teaching of the previous day because trying to teach them everything at once can be overwhelming to the patients. This way, we really get to know the patient and develop trust. We don’t just give patients the tools to manage their heart failure. We teach them how to use the tools,” she says.

When the heart failure coordinators began using the teach-back method to educate patients, they were surprised to learn of some of the gaps in patient understanding, Brinker says. “It opened our eyes to teaching a different way. Now the teach-back method is being rolled out throughout the hospital,” she says.

The heart failure coordinators work with the medical center schedulers to ensure that patients have a follow-up physician visit within seven days of discharge and offer home care services to patients within 48 hours of discharge when possible.

When patients are discharged to home, the nurse coordinators call them within seven days after discharge, and again at two weeks to check on their progress, and answer any questions or concerns. They make sure any post-acute services are in place, assess whether the patients remember what they were taught in the hospital and reinforce the education.