HF program includes beefed-up education
Goal is to reduce readmissions, ED visits
Faced with an increasing number of readmissions of patients with heart failure, Integris Baptist Regional Health Center in Miami, OK, has begun a program to improve the discharge process with the goal of improving the patients' ability to care for themselves after discharge and reduce the likelihood of readmission.
"We were having a high number of people with congestive heart failure who were being readmitted. We researched readmissions due to heart failure and determined that it was likely because they didn't understand how to manage their condition after they got home," says Linda Hollan, RN, BSN, CDE, ACM, director of case management.
Holland cited research from the Agency for Healthcare Research and Quality (AHRQ) that shows that avoidable readmissions are not diagnosis-specific.
"Causes of readmission are poor discharge instruction, poor patient understanding of how to use medications, lack of knowledge of their disease process, and poor transfer of information to ambulatory caregivers such as primary care physicians and nursing home staff," Hollan says.
The program that Integris Baptist Regional follows, Project RED (Re-Engineered Discharge), was developed through research funded by the AHRQ, Hollan says.
"AHRQ has now funded Joint Commission Resources to assist hospitals in the implementation of a patient-centered standardized approach to discharge planning and disease-specific education and provided tools to participating hospitals to facilitate intensive education and post-discharge follow up," she says.
Integris Baptist Regional is licensed for 117 beds and has an average census of about 40 patients. The case management department is staffed by two full-time RNs, one of whom, Hollan, also is the care management director. The case managers cover the hospital from 7 a.m. to 6 p.m. Monday through Friday, a half-day Saturday, and are on call 24 hours a day.
When a patient is admitted with congestive heart failure as a primary or secondary diagnosis, Hollan is notified and coordinates care for that patient, provides intensive education on the condition, then calls the patient after discharge to make sure he or she is following the treatment plan and is not having problems.
While patients are in the hospital, Hollan spends a lot of time making sure they understand their diagnosis, their medication regimen, and their diet and exercise plan. She works with the rest of the treatment team to develop an individual care plan for each patient.
"The role of case manager at our hospital is to be a patient advocate and to make sure we do what is best for the patient and that patients are at the right level of care at the right time," Hollan says.
The care plan includes information about the diagnosis, symptoms, and signs to watch for and what patients should do in case they have problems.
Hollan has developed educational handouts written in simple, easy-to-understand language.
"The majority of people who have congestive heart failure don't understand the disease. I help them understand that heart failure can be more deadly than cancer and if they don't follow the treatment plan, every time they have an exacerbation, it damages the heart more," she says.
She writes down each medication using both generic and brand names, and describes what it's for and how to take it. She divides the list into morning, noon, afternoon, evening, and bedtime medications to make it easier for patients to take the medicine as directed.
"I follow the Project RED guidelines for patient teaching, using the teach-back method to make sure the patient understands what I'm trying to teach them. I talk in-depth about the importance of following their diet, weighing themselves at the same time each day, and give them a calendar that they can use to record their weight. If they don't have a scale, the hospital provides one," she says.
Hollan educates smokers on the importance of quitting and talks to the patients about being physically active within limitations.
"For instance, walking is a good activity, but they should be able to walk and talk at the same time. If not, they're too short of breath and should rest," she says.
Hollan calls each patient the day after discharge and usually makes additional follow-up calls to make sure they are managing their condition.
She asks them specific questions about their medication, their weight, their adherence to the treatment plan, and determines if they have follow-up appointments with their physician. She gives them her cell phone number and encourages them to call if they experience symptoms such as shortness of breath or have questions or concerns.
"One of the concerns many patients have is that it's difficult to get the doctor on the telephone. As a case manager, I already have a relationship with the individual physicians treating these patients. If patients are gaining weight or having other problems, I can talk to the physician, get an order for a medication change, and keep the patient from coming to the emergency room or being rehospitalized," she says.
When a nursing home called Hollan to say that one of its patients had gained a lot of weight, Hollan went to the nursing room, assessed the patient, and concluded she was fine. She called back the next day to check on the patient.
"The goal is to keep patients from having to come back to the hospital. I didn't want to call the physician until I had checked on her myself. It turned out that the scales probably were faulty," she says.
Before the project started, Hollan telephoned patients with congestive heart failure who had recently been discharged from the hospital, and asked specific questions to determine whether they were complying with their treatment plan.
She determined that many of the patients didn't fully understand their condition and how to manage it. For instance, one patient stopped taking his diuretic because he had lost eight pounds and didn't think he needed to lose any more weight.
"Based on the results of the interviews, we concluded that making post-discharge telephone calls could help keep patients from needing to be readmitted," Hollan says.
The hospital broke out its patient satisfaction data from heart failure patients to create a patient satisfaction baseline that can be compared with responses of the patients who participate in the heart failure program, says Alice Hunt, MBA, the hospital's director of service excellence.
"We are confident that there will be an increase in patient satisfaction because of the additional interventions," she says.
The hospital also is monitoring readmissions for patients in the program. If the project reduces rehospitalization and emergency department visits, the hospital plans to add staff and roll out similar programs for patients with pneumonia and acute myocardial infarction, Hunt adds.
Faced with an increasing number of readmissions of patients with heart failure, Integris Baptist Regional Health Center in Miami, OK, has begun a program to improve the discharge process with the goal of improving the patients' ability to care for themselves after discharge and reduce the likelihood of readmission.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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