Hospital initiative reduces heart failure readmissions

Transitions in care are the target

By revamping the discharge process and working with post-acute providers, UConn Health Center/John Dempsey Hospital, Farmington, CT, reduced 30-day heart failure readmissions from 25.1% in August 2010 to 17% in March 2012.

Key initiatives included making follow-up appointments before patients leave the hospital, adding automatic dietician, social worker, and pharmacy consults to the heart failure order set, revising the educational materials the patients receive at discharge, and collaborating with community providers on ways to smooth transitions.

"Readmissions are a hospital problem, but they go well beyond the walls of the hospital. We recognize that once patients leave the hospital, we have to work with the next level of care to facilitate the discharge plan and continue treatment," says Wendy Martinson, RN, BSN, QA specialist in the clinical effectiveness and patient safety department.

The hospital assembled a committee of hospital staff and representatives from post-acute providers who meet monthly to collaborate on ways to improve transitions from one level of care to another.

The committee has revised the discharge forms, agreed on using the same educational materials, and works together to improve communication between the hospital and post-acute providers.

The 184-bed hospital, an integrated academic medical center connected with the UConn Schools of Medicine and Dental Medicine, participated in a statewide collaborative on reducing readmissions for heart failure patients sponsored by the Connecticut Hospital Association.

To spearhead the readmission reduction project, the hospital assembled a multidisciplinary team that included the physician leader, Jason Ryan, MD, the heart failure nurse practitioner, dieticians, social workers, case managers, representatives from nursing, pharmacy, and the hospital's outpatient clinics. The team analyzed readmissions and looked for ways to improve the discharge process. One of the first initiatives was to look at ways to make sure that every patient with heart failure left the hospital with a scheduled follow-up appointment within seven days of discharge. The hospital trained the unit secretaries to make the appointments and enter them into the computerized discharge instructions. "We also educated the heart failure clinic staff that patients needed to be scheduled for an appointment within seven days. Four physicians at the clinic agreed to over-bookings to ensure that patients were seen in a timely manner," she says.

While a major portion of heart failure patients discharged from the hospital go to the hospital's heart failure clinic, some are being treated by cardiologists or primary care providers who are not part of the health system.

When the staff can't schedule a timely appointment with these providers, they contact them and ask if they will agree for the patient to be seen in the heart failure clinic just once to make sure they are managing their condition at home and understand their treatment plan. "We have not encountered any problems with this arrangement because we make clear to the providers that we aren' t taking their patients. We just want to make sure they are seen by a physician within seven days of discharge," Martinson says.

The team tackled the patient education process to ensure that everyone who cared for the patients was telling them the same thing and that educational materials were written at a level patients could understand.

Working with students from the University of Connecticut School of Pharmacy, the team created a health-literate medication booklet that explains the different medications typically prescribed for heart failure and lists all the brand names and generic names in each category.

"We found that often patients are taking one beta-blocker or ACE inhibitor when they come in and are prescribed a different one in the hospital. Sometimes they don't understand and take both of them when they go home," she says. The booklet includes questions to ask their doctor, questions to ask their pharmacists, and information on how to safely dispose of unused medications.

The team obtained copies of three different heart failure educational booklets and asked the patients to indicate the one they preferred. "The patients all chose the booklet written on the third-grade level. This helped us understand how we needed to structure our education program," she says.

The hospital created its own Heart Failure Zone sheet, which describes warning signs and symptoms and what to do when each occurs. Patients are instructed to put the zone sheet on the refrigerator using a magnet that shows "red flag" symptoms to watch for and a place for their physician's phone number. They receive a weight chart and are asked to keep it by their scale.

Working with Qualidigm, the Connecticut Quality Improvement Organization (QIO), the hospital obtained special funding through Medicare to create an educational video for licensed and unlicensed staff as well as patients and families. "We also showed this video to our nurses and nursing assistants to make sure they all teach the same thing," she says. (The video is available through Qualidigm' s website:

Whenever possible, the nurse practitioner from the heart failure clinic visits patients in the hospital to start the education on the heart failure zones and to begin to develop a relationship that will continue in the clinic.

The team developed a process to notify the hospital staff of all patients with heart failure. Each morning, the hospital pharmacy sends Martinson a list of all patients who are receiving diuretics. She compares the diuretic list with the patient list and reviews the patient charts to determine which patients have heart failure, then sends a list of the patients and their hospital floor to about 150 staff including unit secretaries, pharmacists, the cardiology and hospital medicine service, the chief resident, social workers, case managers, dieticians, nurse managers, assistant nurse managers, and nurses in the heart failure and primary care outpatient clinics. "I also list patients who are not admitted for heart failure but have a history of it. The staff knows that these patients don't need follow-up but they do need education," she says.

When the list comes out, the unit secretaries put a blue heart next to the patient names on the unit's census board so everyone on the team will be aware. When they receive the email, the social workers know to schedule a complete assessment of discharge needs and nursing knows to start the education process.

When a patient on the heart failure list is ready for discharge, the case manager notifies everyone who receives the daily emails about the discharge date and discharge destination. This alerts everyone on the team to finish what they need to do. The unit secretary knows to make the follow-up appointment. Pharmacy is cued to address the medication regimen.


  • Wendy Martinson, RN, BSN, QA, Specialist in the Clinical Effectiveness and Patient Safety Department, UConn Health Center/John Dempsey Hospital, Farmington, CT. email: