By Melinda Young
EXECUTIVE SUMMARY
A hospital’s heart failure pilot program showed great promise when it launched in late 2019, but is ready for a reboot in the post-pandemic era.
- The program led to a double-digit drop in the 30-day readmission rate for heart failure patients.
- Patients were discharged with a bag of instructions, education, and other items they needed for better self-management.
- The heart failure team used the teach-back method to educate patients about early disease recognition, symptom recognition, and self-management.
A pilot program to reduce readmission rates among a population of patients with heart failure in Brooklyn, NY, proved successful in the fall of 2019. This was shortly before the COVID-19 pandemic’s disastrous impact on hospitals in New York.
Since then, the hospital has survived COVID-19, and the heart failure program is ready for a reboot.
“COVID has decimated us in the last two years,” says Nancy Rizzuto, DNP, MSN, ANP, CCRN, adult nurse practitioner and director of nursing, critical care, and cardiology services at Brookdale University Hospital. “The pilot program was great, and everyone was thrilled with it, but COVID was a distraction. It’s taken us this long to get back into the mainstream to address these problems. We’re trying to develop a cardiac service line for heart failure and to develop a heart failure clinic with infrastructure that allows patients to have better access throughout the system.”
The hospital targeted the program to heart failure patients because the readmission rate was higher than the state and national averages. “There are so many health disparities in our area,” Rizzuto says. “We’re a safety net hospital in our area, and the prevalence of heart disease is astronomical here.”
Barriers to maintaining lifestyle changes and treatment make heart failure challenging to treat. Affordability of medication is just one factor. Other barriers are lack of access to ambulatory care, lack of insurance to cover the most optimal medication, and cultural dietary habits.
“In our hospital, we partnered with the American Heart Association [AHA] to see the guidelines and where we could go to best serve our population,” Rizzuto explains. “In doing an assessment [of standard practice], we found there was no disease management referral, and we were not getting follow-up visits within seven days.”
Also, post-discharge phone calls were lacking, and many patients were not discharged with the proper medication.
“We started the project in 2019, before COVID-19, and the first thing we did was gather data and hold multiple team meetings with everyone involved,” Rizzuto explains.
Creating a Heart Failure Team
Data showed only 11% of patients were referred to any kind of follow-up care, says Greg Charles, MHA, program director for cardiology services and angioplasty specialist at Brookdale University Hospital. “This was alarming, but also not surprising,” he says. “We gathered reports, met with the director of heart failure, and had online conversations. We discovered that we needed to increase the ACE inhibitors at discharge.”
Even though staff were making appointments for heart failure patients, there was no heart failure clinic available for referrals. “That was the impetus,” Charles says.
They developed a heart failure team within the organization and partnered with long-term care facilities to contact more heart failure patients. “We decided there needed to be follow-up visits and some contact with patients within 48 and 72 hours of discharge,” Charles says. “We looked at patients’ data and realized there was a need to send patients home with a bag of goodies — instructions, things to document, lifestyle modifications, and rehab.”
Patient Education
Data suggested a high percentage of noncompliance with medication regimens, which they attributed to a lack of education, Charles adds.
The next steps were to upgrade patient educational efforts and give patients multidose pill dispensers. “We came up with a plan to train nurses on how to teach patients,” Rizzuto says. “We used the teach-back method. A lot of things are not being absorbed, so [providers] found time to sit with [patients] and teach them about early disease recognition, symptom recognition [such as] shortness of breath.”
At bedside, nurses taught patients how to care for themselves and recognize symptoms early, Rizzuto says. Case managers ordered scales for patients who did not own one. The team made sure patients went home with the necessary medications. These prescriptions were either filled in the hospital pharmacy or patients were given a 30-day voucher. Without insurance, the medication could cost as much as $700. But most insurances covered it, and the voucher helped those without coverage.
Head nurses were designated to call patients within two or three days of discharge. They asked patients if they experienced any symptoms or problems and whether they were staying on their diet.
“Did they have access to a bathroom if they were going out?” Rizzuto asks. “I’d advise them to take their [diuretic] medication around 5 a.m. so they could go out in the afternoon and enjoy their time, and they could take a second dose at night.” Just having someone call and talk to the patients helped to improve adherence, she notes.
Even before the pandemic, staffing was a challenge, but nurse managers found time to make the follow-up calls.
“Say the call was to be made on Monday for a Friday discharge — either the assistant nurse manager or the nursing manager made the call,” Rizzuto explains. “[Initially], there were 47 patients in the study, and in the first month, we had six readmissions — decreasing the readmission rate by 12%.” After three months, it declined by 16.6%.1
Restructuring Roles
Case managers’ role changed for the program as well. They made sure patients could be followed by a physician, who would follow them in their practice area and not in the cardiology clinic.
“We restructured case managers’ roles a little bit,” Rizzuto says. “Case managers called to make an appointment with cardiology, and they made sure patients had the supplies they needed to go home. Every single person on that team had a role, and they did it beautifully. Case managers would step in to help, or if a case manager wasn’t around to make sure a person was being discharged, nurses would pick it up.”
The start of the care management process began on the first day of admission, and teaching patients began in the first 24 to 48 hours. Case managers were involved on day one, ensuring home care visits were set up and patients obtained their packets and prescription vouchers.
Pharmacists helped by prescribing patients 30 to 60 days of medication. Even if the patient’s insurance did not cover it, starting the patient on the medication for a month or two would be helpful, and a different drug could be used after that.
Measuring Outcomes
The AHA hosts a registry platform that can assist with measures and outcomes for heart failure patients. This creates an 11-page database for each patient, and it is extensive in assessing patients’ medical history, medications, weight, lab results, and more, Charles says. For example, the registry platform includes 22 options for race, six options for patient-identified sexual orientation, and seven options for patient gender identity.2
Under discharge information, the platform asks about the patient’s discharge disposition on the day of discharge, and includes these eight options:
- Home;
- Hospice — home;
- Hospice — healthcare facility;
- Acute care facility;
- Other healthcare facility;
- Expired;
- Left against medical advice;
- Not documented or unable to determine.
“I absolutely recommend [case management/providers] get involved with the AHA heart failure registry,” Charles says.
The database helped the hospital learn more about discharged patients, their lifestyle changes, early symptoms, and new medications. “This is important because you can’t send patients to follow-up if they don’t know what they need,” Charles explains. “A lot of these patients, when they come into the hospital, have a long list of problems, and heart failure is one of them.”
They also may be diagnosed with diabetes, high blood pressure, and/or obesity. They might have a full bag of medication they do not take regularly. The patient population also may be low income, and their dietary intake is not optimal.
“In general, they’re not very well medically managed,” Charles says. “Hence, by the time they get to the hospital, there are several problems that have gone unchecked for years.”
There is a great need for a heart failure center that incorporates the care management and coordination in the pilot program. It would bring greater consistency and potential to reach more heart failure patients. The center would handle uninsured and underinsured patients.
A heart failure center could help the health system reduce the 30-day readmission rate even more dramatically once patients are managed on an outpatient basis.
“When you aggressively manage them and are monitoring their heart rate, the readmission rate will go down,” Charles says. “We’re excited about starting with this patient population.”
REFERENCES
- Rizzuto N, Charles G, Knobf MT. Decreasing 30-day readmission rates in patients with heart failure. Crit Care Nurse 2022;42:13-19.
- American Heart Association. Get With the Guidelines. Last reviewed Aug. 1, 2022.
A hospital’s heart failure pilot program showed great promise when it launched in late 2019, but is ready for a reboot in the post-pandemic era. The program led to a double-digit drop in the 30-day readmission rate for heart failure patients.
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