Reduce CHF hospital stays with protocol
Gaining doctors’ trust was crucial to success
Congestive heart failure patients often are "frequent flyers" in a hospital’s emergency room, particularly as their disease progresses. But it’s possible for home care agencies to halt this trend.
Amicare Management Services of Novi, MI, has invented a protocol that in some cases has drastically reduced hospital readmissions for CHF patients.
CHF patients seen at Amicare Home Health Care in Bloomfield Hills, MI, had 24.5 hospital readmissions within 30 days during July-September of 1996. That same office had a 2.4 readmission rate nine months later, says Gwen Clark, RN, BSN, a team leader of the agency, which serves a suburban area of Detroit.
Amicare’s protocol calls for intramuscular or intravenous diuretics, close monitoring, patient teaching, monitoring of lab values, and other supportive activities.
This protocol, part of the Hearts at Home program, contributed to saving overall health care dollars (which the company has not yet estimated) because hospital visits are more costly than home care visits. And it gave the home care agencies a new service to market to referral sources.
"We were able to save money by reducing time in the hospital and avoiding emergency room visits," says Margaret Berkhousen, RN, clinical specialist for quality improvement and risk management for Amicare Management Services.
Nationwide, home care visits cost considerably less than hospital visits, so any reduction in hospital lengths of stay and decreases in emergency room visits will save money, Berkhousen says.
The protocol has shaved a couple of days off the CHF patients’ average hospital length of stay. However, statistics for a companywide average on readmission rates and actual cost savings aren’t available.
The Bloomfield Hills office achieved its striking reduction in readmissions only after focusing its efforts on gaining the trust of referring physicians.
Traditionally, CHF patients were prescribed oral diuretics when at home. Then, if the patient’s condition worsened, he or she would have to return to the hospital emergency room to receive intravenous medication.
Berkhousen says Amicare Management Services spent three years developing the CHF protocol, which the company now sells to other home care agencies as part of a management services package. Quality managers who would like to achieve similar outcomes should follow these guidelines, suggested by Berkhousen and Clark:
1. Form a committee of health care professionals who handle CHF patients.
A local hospital developed a continuum-of-care committee to address the needs of CHF patients. Clark was involved in the committee, which included nurses from the emergency department (ED), the acute hospital setting, a subacute care center, an independent living center, home care, and a hospice. The health care professionals worked for different organizations, but they came together to improve the community’s treatment of CHF patients.
A home care agency could take the lead and try to form a similar committee, Berkhousen says.
Each committee member would see CHF patients at different stages of their treatment. "We shared what we do with the group," Clark says. The members developed a cross-continuum clinical pathway, which outlined the steps each would take with patients.
For example, the ED nurse explained what would happen once the patient was admitted to the ED, Clark says. If the patient couldn’t be stabilized in the ED, the ED staff would have the patient admitted to the hospital.
Each phase of treatment fed into the next phase, forming a continuous circle. The committee experience taught Clark and other participants what each department would do when treating CHF patients.
"There’s more communication now between all caregivers of the patient," Clark says. "Before, everyone did their own part, and we didn’t know what the others were doing. Now I call the manager of the floor that’s taking care of a patient."
2. Keep in touch with other health care professionals.
Constant communication has helped Amicare stop duplication of services, and it’s created better patient education, Clark says, using instruction about diet as an example.
"These patients are supposed to be on a low-sodium diet," she explains. But suppose the patient isn’t following the diet instructions the home care agency gave him. For example, the patient might like to add salt and eat frozen foods, although these are not on the recommended diet.
"So we’ll talk with the dietitian in the hospital and say, this is how far we’ve come with diet teaching, but he’s still having a hard time with it,’" Clark says.
Then the hospital dietitian could meet with the patient to encourage him to stay with the diet.
3. Educate hospitals, physicians, and other referral sources.
Clark says Amicare gave presentations to hospital nurses, physicians, and others, sharing information about the Hearts at Home program. The agency encourages its referral sources to make referrals earlier in the patient’s illness, she says.
Educate patients with movie, booklet
This way the home care nurse can teach the patient to watch for weight gain, monitor the diet, and exercise. "We have a movie called Just a Little Heart Failure,’ and a teaching booklet that is written in terms the patient and family can understand," Clark says. "An informal patient support group of family and friends makes living with the disease of CHF easier."
Working together, the physician, the health care team, and the patient and family can greatly improve the patient’s outcomes, she adds.
Several years ago, physicians and hospitals were not referring CHF patients to home care until after the patients had been hospitalized several times. "By getting them earlier in their illness, you can teach them better habits and teach them how to take control of their disease so they can stay well longer," Berkhousen says.
4. Meet doctors face to face.
It was difficult to gain the physicians’ trust, Clark acknowledges. "It’s most important to have the physician buy-in to the program, and that trust just took a lot of time to develop," she says.
Once physicians started to refer patients for intravenous medication, they started to see how the patients’ rehospitalizations declined. This was evidence to some that they should continue with the referrals.
"Of course, there were some holdouts," Clark says, adding that the agency’s nurses took extra steps to gain these doctors’ trust.
One recent example involved the case of a CHF patient who frequently had trouble breathing. The agency gave him oral diuretics, but these didn’t prevent him from entering the acute phase, Clark says. The doctor still refused to give the order for intravenous diuretics. So the home care nurse accompanied the patient to the doctor’s office and talked to him about her concerns for this patient’s health.
Clark says the physician was impressed with how much the nurse knew about CHF and her genuine concern for the patient. Because the nurse was so knowledgeable about the disease process, as well as her pharmacological treatment methods, he agreed to allow the nurse to implement the protocol, including the administration of IV diuretics.
"The patient became acute again, and we gave him the IV medication and kept him out of the hospital," Clark adds. "We gave him the IV diuretics four times in the last month and he hasn’t gone back to the hospital."
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