Heart at home’ program provides better outcomes
Cutting hospital readmissions from 20% to 1%-3%
Congestive heart failure (CHF) was one of the most common diagnoses for a Louisiana home health agency, and it appeared that too many CHF patients were readmitted to the hospital.
So Bossier Medical Center Home Care Services of Bossier City, LA, addressed the issue with a quality improvement project aimed at reducing hospital readmissions.
The hospital-based agency, which has 3,200 visits a month in a rural area of northwest Louisiana, started the project in 1996. Agency officials studied hospital records and found that 20% of home health patients with CHF had been readmitted to the hospital in the first quarter of 1996, says Barbara Cunningham, RNC, director.
"Then we reviewed each patient’s history to see if there was something we could have changed," Cunningham says. "And we found that we could have changed something for over half of the patients. That was enough to get excited about it."
So the agency launched its QI project, calling it the Heart at Home program. For the first three quarters of 1997, between 1% and 3% of the CHF patients were readmitted for that diagnosis, as compared with the 20% readmitted previously, Cunningham says.
Moreover, surveys showed that patient satisfaction remained at 100%.
Here’s how the agency did it:
1. Review records.
When reviewing records, Bossier home health nurses realized they could have prevented many of the hospitalizations if they had been permitted to temporarily increase the patients’ diuretics.
If that’s done soon enough, it can prevent the patient from having an acute episode. Although a nurse might notice that a patient has gained three pounds when there has been no change in the medication, there is nothing she can do without first waiting for a physician’s order, Cunningham explains.
"But you don’t always get those orders right away, so those patients could end up in the emergency room," she says.
A CHF pathway resolved this problem by having physicians sign standing or "what-if" orders. One example of a standing order is: "If a patient has gained over three pounds, double their Lasix," Cunningham explains. Lasix is an oral diuretic.
2. Create a CHF clinical pathway heavy in successive patient education visits.
"When we were reviewing these patients, we weren’t sure they understood the symptoms of exacerbation," Cunningham says. "So we needed to concentrate on their education, and we did that by putting them on a clinical pathway."
A team of staff nurses and the agency’s assistant director reviewed some existing clinical pathways, and then created their own. The biggest difference between the pathways they reviewed and the one they created was that Bossier’s clinical pathway calls for more clusters of visits, especially at the beginning.
The pathway suggests nurses visit a CHF patient four days in a row in the first week, and then visit in clusters of three, two, and finally single visits just for maintenance. The visits will focus on education, but include having the nurse monitor the patient’s weight and other signs and symptoms.
"Having those visits all in a row seems to make a big difference in their education," Cunningham says.
The visits are more intense, and each day has a set routine, according to the pathway, she adds. And the visits are made in a row, even if that means a nurse goes to the home on a Saturday or Sunday.
All staff nurses rotate shifts that include weekend work, and they are not compensated differently for those hours, Cunningham says.
Nurses use each visit to emphasize one or two important things that the patient needs to learn, says Robin Loucke, RNC, assistant director and staff educator.
"They won’t remember it if you try to teach everything you need to teach on one visit," Loucke says.
The clinical pathway also lists interventions and physician standing orders to double diuretics in the event a patient gains weight or has other signs or symptoms specific to the disease exacerbation, Cunningham says.
"If that doesn’t work, we would always try an IV diuretic," she adds. This would depend on the physician and whether he or she was comfortable writing standing orders for the IV diuretic.
3. Get pharmacists involved.
Pharmacists from Bossier Medical Center became involved in the process, almost by accident. It first happened because one patient needed to receive Primacor, a type of medication that typically is not used by patients in their homes. So the insurance company asked the home care agency to prepare to give the patient Primacor at home. This patient was the first to be put on a CHF clinical pathway.
Pharmacists joined the CHF team and helped to develop a list of patient symptoms that physicians could use when choosing standing orders for the home care agency to follow. The pharmacists also gave advice on drug regimens and supported the agency’s goal to help patients avoid unnecessary hospitalizations.
Having pharmacists involved helped to boost physicians’ confidence in the pathways and in the home care agency’s ability to carry them out, Cunningham says.
"They’re real interested in this project, which is helpful because it’s more than one discipline making suggestions to physicians," she adds.
4. Give physicians a "book" on the pathway.
The team compiled all the CHF pathway information in a book that could be given to physicians. The book included details about specific therapies in the home and how these would be conducted.
The book has an overview of the program, and it includes examples of the different types of standing orders. It also has the outcomes measuring tool and the pathway, and it describes in detail tasks the agency will perform and how this will be accomplished.
For example, the book describes exactly what Medicare requires for a patient to be given Primacor at home. The major requirement is that the patient be given certain hemodynamic measurements, which are measures of the effectiveness of how the heart is working, in order to qualify. Cunningham says these measures typically are not required by private insurers.
The details lent the program a lot of credibility, Cunningham says.
Nurses met with physicians either individually or at physicians’ hospital meetings. They gave them the booklets and discussed what the agency planned to do as far as patient education and early intervention according to symptoms to reduce hospitalization rates for CHF patients.
"Your physicians have to have a certain amount of faith in your assessment skills and trust you know what you’re doing," Cunningham says.
Some physicians questioned whether the agency planned to keep patients homebound even if they didn’t need to be. "We said that of course, we would not. When a patient is through and in good shape, we’ll discharge the patient from our services," Cunningham says.
But if a discharged patient calls the agency for help, then the agency would contact the physician and ask for an order to have the patient readmitted.
The agency’s efforts paid off. Most of the primary care physicians and many of the cardiologists now send patients to the Heart at Home program.
"It has become popular among the doctors," Cunningham says. "The hospital’s cardiologists think we ought to expand the program."
So far, the Heart at Home program includes post-myocardial infarction, post-angioplasty, and post-coronary artery bypass graft patients, as well as CHF.
5. Educate staff and patients.
The agency held several staff inservices, lasting a couple of hours each for a total of eight hours. These covered the pathways, treatments, patient teaching, and medications.
The team developed patient-teaching materials that reviewed the clinical pathway in simple language. "Nurses give these to patients, and they keep them in a notebook that we gave them to keep track of their weight and other details," Cunningham says.
CHF patients often let their symptoms flare up until they become emergencies, so nurses focus on teaching them how to intervene early in the process, Cunningham explains. "We work to change their behavior."
The written material was kept brief, Loucke says.
"We didn’t want to overload the patient with oodles of paperwork because they’re more likely to read a small amount," she adds.
The material given to patients focuses on the following information:
• diet restrictions;
• daily weights;
• when to notify nurse or doctor;
• medical appointment follow-through and why it’s important;
• assessment of edema;
• a description of congestive heart failure;
• signs and symptoms of CHF;
• what brings on an attack.
"We stuck to teaching those things and making sure they understood them 100%, and we didn’t bombard them with a lot of paperwork because we wanted them to read it and follow through," Loucke explains.
Nurses help patients recall what it feels like to have a symptom of an acute episode, she adds.
For instance, a nurse might ask a patient, "When you’ve had these attacks before, have you noticed that your breathing rate has increased?"
Or the nurse might ask, "Did you notice that you didn’t have trouble breathing while lying down, and then all of a sudden you did have trouble?"
These types of questions work better than simply telling a patient to watch out for shortness of breath, Loucke explains. "We tried to relate it to an experience they have had," she adds. "Everyone’s shortness of breath is different."
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