Education efforts slash CHF readmissions
Patients get heavy attention after discharge
A pilot study at Barnes-Jewish Hospital in St. Louis cut congestive heart failure (CHF) related admissions in half and in turn spurred the staff to increase efforts to educate more CHF patients on controlling this expensive-to-treat disease.
Much research confirms that at least 50% of readmissions from CHF are due to lack of patient adherence to care plans developed by clinicians. Designers of the Barnes-Jewish study, conducted by the hospital’s Division of Cardiology, wanted to show that patient education would improve compliance, says Carol Wittenberg, RN, BSN, who was hired to fill the CHF nurse coordinator position the hospital funded as a result of the successful study.
With the average Medicare payment for treating congestive heart failure, DRG 127, at a minimum of about $3,500, any program that can substantially reduce readmissions is bound to benefit either the payer, the patient, the hospital, or all three.
The next Barnes-Jewish CHF research project will be a nurse-directed CHF clinic. The emphasis will continue on intervention after discharge.
Success lies beyond hospital walls
"Most of our intervention [in the study] took place after the date of discharge and I believe this is where the impact on the patient was made," says Wittenberg, who participated in the pilot study and eventually will leave her position with the hospital’s CHF program to head the clinic. "The hospital is not the best environment for learning and retaining information."
Among other things, the clinic will fill the gap for patients who, under Medicare regulations, don’t qualify for home care. Patients will come to the clinic for follow-up care. As with the study and the hospital program, the focus will be on medication and dietary compliance and social work intervention.
Meanwhile, in her current role, Wittenberg assesses every patient’s learning needs. Although every patient in the pilot study saw a dietitian and a social worker and received a home visit, these CHF interventions now depend on each patient’s unique needs. If a patient isn’t homebound, for example, he or she would not qualify for a home visit.
Because many more patients are in the hospital program than in the pilot, she relies heavily on communication with home care services. She also has solicited help from other disciplines — such as dietitians and social workers — to conduct some of the follow-up phone calls.
Wittenberg is collecting data on readmissions, but sees no reason why the results of the pilot study won’t be repeated.
Key to the program’s success is providing detailed information tailored to the patient. "If you were to ask CHF patients if they follow a low-salt diet, the answer from 99% of the patients would be Yes,’" Wittenberg says. Therefore, the educator must ask patients what they ate in the past 48 hours. While they may not add salt, they could be eating high-sodium canned foods.
Other professionals who participate include:
• A pharmacist.
Although nurse educators taught about the patient’s medications during the study, now a pharmacist meets with the patient before discharge and goes through the list of discharge medications.
• Home health nurses.
When a patient is eligible for home care, Wittenberg arranges at least one visit by a home health nurse. During a visit, the nurse surveys the pantry and makes sure the patient understands how to take his or her medications.
Follow-up call pinpoints behavior
Follow-up phone calls are made over a three-month period after the patient is discharged. Questions include:
— How has your weight been?
— How is your breathing?
— Are you having any problems with your medications?
— Describe what you ate over the last few days.
"We pull specifics from the patient, encouraging them to keep a record of their daily weight," Wittenberg explains. "We don’t just settle with, Oh, it’s been fine,’ but ask exactly how much they’ve gained or lost."
To conduct the core education, Wittenberg follows a 15-page booklet written for the study called Congestive Heart Failure, A Patient’s Guide. The book describes congestive heart failure, its causes, the symptoms, the ways it is diagnosed, and treatments.
[Editor’s note: Nonprofit hospitals can purchase the 15-page booklet, Congestive Heart Failure, A Patient’s Guide, for $2 per copy, or $1.50 per copy for more than 10 copies. The booklets are available to for-profit hospitals by a licensing agreement. For more information write: Carol Wittenberg, Congestive Heart Failure Program, Barnes-Jewish Hospital, 216 S. Kingshighway Blvd., St. Louis, MO 63110. Telephone: (314) 454-5160.]
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