Providers team up to cut HF readmissions

High-risk patients identified early on

A Hartford (CT) Physician Hospital Organization's program to reduce the rate of readmission for patients discharged with a primary diagnosis of heart failure has kept the readmission rate at between 11% and 13% for the last year, according to Linda Conroy, RN, BSN, clinical integration case manager for the Hartford Physician Hospital Organization, a partnership between Hartford Hospital and Hartford Physicians Association.

Conroy acts as a liaison between Hartford Hospital, the physician association, community home health agencies, and skilled nursing facilities to help patients with heart failure navigate the healthcare system and keep their conditions under control. To ensure continuity in care, the hospital, physician group, and post-acute providers have collaborated on the education process to ensure the patients receive the same education in all settings.

"We try to identify the high-risk patients early on so we can start to work with them," Conroy says. She attends heart failure physician rounds three days a week and discusses problem cases with the nurses and physicians. Most of her referrals come from the rounds, and most are being discharged to a skilled nursing facility or to home with home health services. Few are discharged to home with no services.

When she receives a referral, Conroy goes to the patient room, introduces herself, explains her role, and gives the patient or family member her card with her phone number in case they have questions. "I don't contact the patients again while they are in the hospital. Patients see so many people while they're hospitalized that it gets confusing. I want them to have a face to go with my voice, but I don't want them to confuse my role with the role of the discharge planner," she says.

When patients are being discharged, Conroy reviews the discharge summary and the physician orders to make sure they are in sync. If there is conflicting information, she obtains clarification and notifies the staff at the next level of care. She calls the patients' primary care physicians, finds out if they received the discharge summary and, if not, faxes it over to them.

"Communication between the hospital, the doctor, and the next level of care is critical to successfully keeping patients from being readmitted," she says.

If patients are discharged to home with home care services, Conroy calls them to check on them and follows up with the visiting nurse. She asks the home nurses to keep her updated whenever they see patients. Conroy calls the patients discharged to home at intervals that depend on their needs and the severity of their illness. She might call patients several times a week if their condition is not stable, or as infrequently as once a week if they are doing well. Conroy asks how they feel, if the visiting nurse is coming regularly, if they have seen a doctor, and asks about their experiences with telemonitoring equipment if they are using it.

"I often talk to family members as well," she says. "Sometimes caregivers call me because they are frustrated and tired and need someone to talk to."

If the patient is stable at the end of 30 days, Conroy stops following them. In the case of patients who are having difficulty, she manages them beyond 30 days.

When patients are discharged to a skilled nursing facility, Conroy calls the facility, asks them to keep her informed about the patients' progress, and makes sure the patients see a cardiologist within 5-7 days after discharge. She calls the skilled nursing facility intermittently to check on the patients and to find out when they are going to be discharged. She receives the discharge paperwork and makes contact at the next level of care which, in most cases, is the home health agency.

The most successful cases are those when Conroy and the visiting nurse are in constant contact. When patients have an exacerbation after discharge, the home care nurse gets in touch and discusses the symptoms. "The home care nurses call me because I'm easy to reach on the telephone," Conroy says. "I have a close working relationship with the doctors and can reach the patient's physician and get orders to adjust the medication, many times when the home health nurse is still in the patient's home."

The close communication between Conroy and the home health nurse is particularly effective when uninsured or underinsured patients are being treated at the Hartford Hospital Clinic. "The physicians at the clinic are very busy, and they aren't there every day. Getting in touch with them can be frustrating to the visiting nurses. The doctors know me, and most of the time I can reach them and get them to adjust the medication," she says.

For example, one patient, who was on IV dobutamine and IV furosemide, historically had been hospitalized at least every two weeks because he had problems keeping his condition under control. Conroy was able to coordinate adjustments in the frequency of the infusions with the home health nurse and the doctor. As a result, the patient has been staying out of the hospital for much longer periods of time.

"Communication is the key to keeping high-risk patients out of the hospital," she says. "We give them a lot of support in the skilled nursing facilities and at home and keep providers at all levels of care informed."


For more information contact:

  • Linda Conroy, RN, BSN, Clinical Integration Case Manager, Hartford (CT) Physician Hospital Organization. Email: