Multi-faceted program cuts HF readmissions
Components include education, follow-up
After Good Samaritan Hospital Medical Center in West Islip, NY, began a comprehensive process to reduce readmission rates for heart failure patients, readmission rates dropped from 21.1% to 15.3% in just a few months.
"When the project started, the hospital's readmission rate for heart failure was about above the national average. We knew there was an imperative to look at the current processes to see what was driving the readmissions," says Rita Regan, RN, BS, CPHQ, quality management coordinator for the 537-bed hospital.
As quality management coordinator, Regan was part of a multidisciplinary team, headed by care management, that analyzed heart failure readmissions to determine the reasons patients were coming back. Other disciplines on the team included nurse managers from the units where heart failure patients were admitted and representatives from nutrition, pharmacy, physical therapy, nursing performance improvement, and Good Samaritan's home care agency.
After researching best practices in reducing readmissions, the team decided to take two approaches: changing the behavior of staff and patients during the educational process, and providing an ideal transition between levels of care.
An early step in the process was to identify the patients' primary caregivers and involve them in all aspects of education and transition planning. "We wanted to determine the best person to receive the education, if it's not the patient," Regan says. "If the relative or caregiver isn't available for on-site education, we ask them the best time for a telephone conversation."
The team looked at ways to standardize patient education among units in the hospital and between levels of care. They collaborated with the Long Island Health Network, a group of 10 hospitals that work together to improve patient care and their home care departments, and chose a standardized booklet that all the hospitals and home health agencies use to educate patients. "This way, patients are getting the same instructions in the home after discharge as they got in the hospital," Regan says.
The booklet includes a weight log in which patients record their daily weight. As part of the behavior changes for staff and patients, the team recommended that the hospital staff have the patient write down their weight in the book to get them accustomed to doing it when they get home.
The care managers educate patients and family members on the importance of making the follow up visit and taking their educational materials, discharge instructions, and medication list with them. "Medical treatment is just part of the whole picture," Regan says. "We found that we needed to educate the patients on the risks of not following their treatment plan. We want to get patients to take ownership of their condition and to understand the risks of non-adherence."
The team educated the entire staff including nursing aides, nurses, care manager, and dieticians on using the teach-back method for patient education. "In order to implement our recommendations, we got our clinical council to take a stand and say that teach-back was the standard method for all clinicians to use to educate patients," she adds.
The team members monitored the hospital's video-on-demand system that provides patient education in the patient rooms, and they found that usage was very low. As a result, the team educated the staff on how to use the video-on-demand system and created an addendum to their identification badges with instructions on how to use the system. It's now a hospital standard for heart failure patients and their families to view the video "Heart Failure — Getting Ready to Go Home." The team put on a skit attended by 400 staff members that demonstrated the right way to conduct education including using teach-back method and using the educational video.
One key to the success of the project is developing close relationships with providers across the continuum, Regan says. The team presented their teach-back skit at the home care agencies in the community. "It was well-received and showed them what we were doing in the hospital to support them by providing patients information they needed after discharge," Regan says. The team collaborated with community skilled nursing facilities home on ways to keep heart failure patients out of the hospital. "It was a real eye opener for us to learn that patients in a skilled nursing facility get to choose their diets," Regan says. "We worked with the dieticians in the skilled nursing facilities on the importance of educating patients to make healthy choices."
Because patients typically are not weighed daily in skilled nursing facilities, the team developed a red-flag form that identifies heart failure patients and alerts the skilled nursing staff that the patients' weight should be monitored daily for two weeks, then twice a week. The team educated the staff to call a physician to adjust the medication if the patient gained weight.
Members of the care management team visited community physician offices and asked them to ensure that heart failure patients could obtain a post-discharge follow up appointment in a timely manner. They worked with the hospitalists to make sure the discharge summary gets to the patient's primary care physician or specialist in a timely manner.
The team continues to monitor readmissions and reviews the charts of readmitted patients every month determine if anything could have been done differently.
"This process has proven to provide a safer transition home, to discharge the patients with a lot more education, and to get them to the physician for an early follow-up visit," Regan says.
After Good Samaritan Hospital Medical Center in West Islip, NY, began a comprehensive process to reduce readmission rates for heart failure patients, readmission rates dropped from 21.1% to 15.3% in just a few months.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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