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Purpose: Reduce the admission rates for heart failure patients by 10% within a 3-month span.
Background/significance: Updated research reflects the importance of coordinated care from inpatient to outpatient, standardized teaching and nurse-driven appointments in the management of heart failure patients during the first 30 days post-discharge. Nurse-driven appointments allow for access, individualized patient education, and closer follow-up. This has been shown to decrease readmission and mortality rates and increase disease understanding and management for these patients.
Description: As part of moving toward a more patient-centered care model, a clinical pathway was developed for post-hospital follow-up care for patients with a diagnosis of heart failure. The focus of the pathway includes a follow-up timeline for the patient, standardized HF education material, inpatient to outpatient communication, and an RN documentation template. This pathway outlines the roles of the RN and provider in delivering care as a team effort to standardize care. Staff will be trained and demonstrate competency on the program objectives and documentation.
Evaluation and outcomes: The program is currently in process; to date we have trained 66 primary care and home telehealth RNs to the clinical pathway and the heart failure patient education packet has been completed, approved by the education department, and is available for distribution to patients. However, the education packet is not available within the charting system at this time. Other metrics that will be compared include pre- and post-implementation facility data for 30-day admission rates for heart failure patients. We will measure the percentage of patients scheduled correctly following the clinical pathway: this will be done by return to clinic orders being placed correctly and patients scheduled with RN prior to discharge.
Conclusions: While this is a work in progress, preliminary reports from patient and staff are encouraging. RNs have sooner and more flexible access than providers which allow for patients to have more frequent follow up. Individualized care plans for HF patients increase success with disease management. Producing standardized models for care will allow for consistency among the primary care clinics and improve communication from inpatient to outpatient and between patients and their care team.
