Post-AMI Discharge Follow-Up Strategies and the Impact on Readmission Rate: Experience from the ACC Patient Navigator Program

Background: As part of the American College of Cardiology (ACC) patient navigator program (PNP) phase II focus MI, we continued risk-specific interventions implemented in phase I to reduce AMI readmissions. Concentration was placed on identifying strategies most impactful on increasing early post-discharge follow-up as it has been promoted as a method of reducing 30-day readmission rates.2

Methods: A multidisciplinary approach was implemented to include the cardiologist, transition nurse, inpatient pharmacist, patient navigator, and the ambulatory care clinic nurse. Special needs were identified during discussions at the team’s daily multidisciplinary rounds. AMI patients received disease-specific education by the transition nurse and pharmacist prior to discharge. The patient navigator scheduled a 7-day follow-up appointment with a cardiology or outside provider based on the patient’s individualized needs prior to discharge. Follow-up phone calls were made 72 hours post-discharge by the transition nurse, and, at a minimum, 30- and 90-day calls were made by the ambulatory care clinic nurse. Each call was structured to solicit specific information regarding cardiac specific medications and symptom management and encourage follow-up appointment compliance and cardiac rehab participation.

Results: Data was collected January 2018 through September 2019. A total of 135 AMI patients were included in the National Cardiovascular Data Registry (NCDR®) Chest Pain-MI Registry™. 60% completed at least one appointment within 30 days post- discharge and 32% completed an appointment within 7 days. Follow-up calls were made within 72 hours; however, very few patients answered the call. requiring a message to be left with the nurse call-back information and appointment details. A total of 15 patients (11%) readmitted within 30 days, with 8 not having a follow-up call or completed appointment. Follow-up calls at 30-days post-discharge averaged a 77% success rate, and 90-day calls averaged 65%. A total of 16 patients (12%) readmitted within 90 days, with 8 not receiving a 30-day follow-up call. Those readmitted had one or more high risk factors including insurance limitations or unfunded status; discharge to assisted living; special caregiver requirements; active transplant evaluation; or having multiple co-morbidities, including cancer, which effected their compliance with cardiology follow-up.

Conclusions: The data reveals that in addition to inpatient interventions, telephonic nurse outreach, and early follow-up can help to reduce readmissions. Increased patient compliance with follow-up was noted in one large internal medicine practice with dedicated ambulatory care nursing staff to conduct post-hospitalization follow-up calls and ensuring a visit was completed within 7-14 days post-discharge.

References
1. Pandey A, Golwala H, Hall HM, et al. Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction. Findings from the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get with the Guidelines. JAMA Cardiol. 2017;2(7):723–731. doi:10.1001/jamacardio.2017.1143
2. Tung YC, Chang GM, Chang HY, Yu TH. Relationship between Early Physician Follow-Up and 30-Day Readmission after Acute Myocardial Infarction and Heart Failure. PLoS One. 2017;12(1):e0170061. Published 2017 Jan 27. doi:10.1371/journal.pone.0170061