Background: Heart failure is one of the costliest chronic diseases in the United States; it is the chronic disease that results in the most readmissions for Medicare patients annually. Patient education and medical monitoring prior to and immediately after hospital discharge are critical to prevent hospital readmission within 30-days of discharge. Primary care nursing and medical management is imperative and plays a crucial role in preventing these readmissions.
Methods: In a primary care community-based outpatient clinic (CBOC), a pilot study was conducted in two primary care provider (PCP) teams to complete a dual-appointment approach: concurrent PCP and registered nurse (RN) appointments on the same day. Nine patients discharged with a HF diagnosis were scheduled both a PCP and RN appointment within ten days of discharge. The RN appointment intervention consisted of a detailed assessment of home activity level, home weights and blood pressures, signs/symptoms at home, as well as nutrition. In addition, an evaluation of needed services such as social work, home telehealth, and pharmacy was done. More importantly, the evidence around HF readmissions was presented in a conversational approach to the patient.
Results: All nine patients had a diagnosis of heart failure with a disease in New York Heart Association class II, III, or IV; in addition, over 50% of the pilot patients had some aspect of coronary artery disease (CAD), atrial fibrillation (afib), diabetes, and hypertension in need of management. All received the dual appointment with 6 days of discharge; none of the nine patients were readmitted within 30-days of discharge. Furthermore, 44% received home telehealth, and 44% received a nutrition referral during the appointments.
Conclusions: This pilot provides insight into the valuable role the RN provides by focusing on evidence-based strategies in preventing 30-day readmission in the heart failure population. This model of care has implications for management of other chronic disease patient populations.