Heart Failure Improvement Across

the ContinuumHospital to Home: Optimizing the TransitionHospital to Home: Optimizing the Transition

January 2009 Florida Hospital Assoc.January 2009 Florida Hospital Assoc.

Peg M. Bradke, RN, MADirector, Heart Care Services

St. Luke’s Hospital, Cedar Rapids, Iowa

February 2006

St. Luke’s joined the Institute for Health Improvement Innovation Project for Transitions to Home.

Work concentrated on the Heart Failure patient.

Strategies in Place

Heart Failure work team in place Congestive Heart Failure class Utilizing BNP to identify HF patients Follow-up phone calls Setting up discharge appointments Pad/pencil at bedside for patient A lot of work on CMS indicators

First Steps

Heart Failure Work Group reorganized to include: Home Care representative Family member of a HF patient Long-Term Care representative Physician Clinic representative

These views added new context to our efforts.

MeasurementHow will we know a change is improvement?

HF 30-day readmission rate: (Unit of focus or hospital-wide) HF is primary, secondary or lower level diagnosis Patient with HF had a readmission for HF within 30 days of a readmission

for HF Use your own definition or CHF Toolkit measures at www.IHI.org

http://www.ihi.org/NR/rdonlyres/708DEB58-6082-453A-B26A-3391290EC0AD/0/MIFCHFPercentofCongestiveHeartFailurePatientDischargeswithReadmissionWithin30Days.doc

Hospital 30-day (all) readmission rate: Patient with HF was readmitted for any reason

For both measures: Exclude chemo day patients treated on the unit If focusing your work on a single unit, the HF readmission or all readmission rates

for that unit will be needed Display monthly on a line (run) chart for last twelve months. 

AIM Statement(From February 2006 Initial Transition to Home IHI Kick-off Meeting)

By January 1, 2007, St. Luke’s Hospital’s Telemetry Unit and Medical Unit will reduce unplanned readmissions by 50% (from 12 to 6%) by improving the transition home process for all Heart Failure patients.

Our methodology will include the patient and caregiver - ensuring that they fully understand their diagnosis, plan of care and follow-up care with physician.

What Changes Can We MakeThat Will Result in Improvement?

Four Key Changes to Achieve an Ideal Care Transition from Hospital to Home:

1. Enhanced Assessment of Patients

2. Enhanced Teaching and Learning

3. Patient-Centered Communication Hand-offs

4. Post Hospital Follow-up

Result of the IHI Collaborative Work on Transitions

Transforming Care at the Bedside How-to Guide

http://www.ihi.org/NR/rdonlyres/8F0551D1-DCD7-4EE7-BEE0-7C0DFBB5F6AB/5867/TransitionsHome_HowtoGuide_Final102207.pdf

Enhancing the Admission

Assessment for Post-Discharge Needs

Enhanced Admission Assessment for Post Discharge Needs

Identify the appropriate family caregivers Partner with home care agencies, primary care offices

and clinics, and long-term care facilities Communicate to all members of the care team the

discharge plan and what needs to happen Estimate the home-going date on admission and

anticipate needs Estimate standard discharge criteria

Heart Failure Work Group Reorganized to Include:

Home Care representativeFamily member of a HF patientLong-Term Care representativePhysician Clinic representative

These views added new context to our efforts.

Sample of White Board

Sample of SBAR Kardex

Date

Weight: □ daily □ weekly □ other____________

SITUATION BACKGROUNDAllergies: RESPIRATORY THERAPY:

O2 via _________ @ __________Oxygen Titration Protocol: Y NKeep sats _______________Trach tube/Size________________□ Cuffed □ Fenestrated

SIGNIFICANT EVENTS THIS HOSPITALIZATION:

CODE STATUS: □ Full □ DNR □ Other:

Advanced Directives: □ On Chart □ Family to Bring □ None

Emergency Contact: Past Medical History: HTN Diabetes Arthritis Renal disease CHF

HHN:

DVT prophylaxis: TED’s SCD’s Other: ___________________

Inc Spirometry/C & DB: Patient Requests/TAKE 5 :

IV ACCESS : Picc ML/single/double/triple/Power Central Line Port: ____________ Saline Lock Other: __________

Site D done:_________ due:_________Cap D done:_________ due: ________Tbg D done: ________ due: _________IV fluids:

Precautions: Seizure Skin Elopement Aspiration Fall Suicide Hx of falls Restraints Communication: HOH:R/L; glasses; dentures;

non-English speaking: _____________SAFETY INTERVENTIONS: Bed Alarm Chair Alarm Safety Belt Frequent toileting Overlay Alarm Enclosure bed Other ____________

Family Dynamics/Issues affecting care:

Religion/Culture beliefs affecting care:TELEMETRY: ____________ Reason: ___________ ICD/ Pacer: Rate ____________ Pacer: Rate ___________

Labs, Radiology ProceduresMonday:

Blood TXM: ___________ units _________ date __________ units on hold Tuesday:

Wednesday:Special Equipment: Softcare mattress Specialty mattress/bed _______

Mode of transport: □ Cart □ WheelchairThursday:

Activity:Friday:

ISOLATION: Last Screen _______________ □ VRE □ MRSA □ C diff □ Other Saturday:

Weight bearing status: _______ Lift Equip: Ma

Sunday:

Daily/Weekly Labs:

Adm date: __________ DIAGNOSIS : ___________________________ OR: _____________ ADMITTING/PRIMARY: _____________________________

ASSESSMENT RECOMMENDATIONVITALS: □ Routine □ Other: ____________Call if: SBP less than ______ greater than _______Temperature greater than _______ degreesHR greater than _______ or less then _______RR greater than ________Oxygen SAT less than ______ %

Flu: assessed ________ given ________ Pneumonia: assessed ________ given ______

Caregraph focus /Pt goals: Focus #1: _____________________________

Bath: Bed Shower Needs Assist Hibiclens Date: ________

Treatments/OtherACCUCHECK: □ QID □ BID □ Other _________ □ SS ____________ □ Insulin Infusion Referrals: □ PT □ OT □ SP language

□ SP swallowing □ Hospice □ ET □ Cardiac/Pul.Rehab □ Palliative □ Social Services

I & O: Yes No

Mental Status: □ Alert □ Oriented □ Confused □ Combative □ Forgetful □ UnresponsiveDIET: □ NPO □ Soft □ Clear Liq □ General □ Diabetic □ Full Liq □ DAT □ Other ___________

EDUCATION/ TEACHBACK□ Dx Specific: _______________________□ Falls□ Blood transfusion□ Meds: ____________________________□ CORE Measures□ Treatments: _______________________□ Other: ____________________________

DISCHARGE PLANNING:

Elimination:Bladder: □ BR □ BSC □ Incont □ Foley: size ______ date placed ______ □ St Cath _________ for PVR ________Bowel: LBM ________ □ ostomyOther tubes: □ JP □ NG □ CT □ Other ________

Tube Feeding: Solution: _________________ Per Pump: ___________ ml/hr

Bolus ___________ ml every _____________

Flush ___________ ml every _____________Check Residual ________________□ Salem --# 16/ #18 □ Levine □ Dobb-Hoff□ PEG

CORE Measures: HF, AMI, SCIP, Pnem

Other:

Name:__________________________________________ Room #: ___________________

Communication

Daily discharge huddle at 10:00 AM Bedside reporting Both opportunities to review plan for day and

anticipate discharge needs

Reconcile Medications Upon Admission

Involve the patient and family caregivers, care providers, physicians, pharmacy

Reconcile on admission (suitably trained professional)

Include record of the reconciliation in the medical record

Ensure drug changes during the admission are reconciled, updated, accurate and timely

Consider using a personalized medication

Known reason(s) for readmission. What did the patient or family think contributed to the readmission? Any self-care instructions misunderstood? Evidence of teach back documented? What did the physician or office staff think contributed? Was a follow-up physician visit scheduled? Attended? Number of days between the discharge and physician’s office visit.

Number of days between discharge and readmission Any urgent clinic/ED visits before readmission? Functional status of the patient on discharge? Clear discharge plan documented?

Chart Review Tool

Interview Questions Asked to Patients/ Caregiver Readmitted With Heart Failure

Can you tell me in your own words why you think you ended up sick enough to be readmitted again?

Can you tell me what a typical meal has been for you since you left the hospital? What did you have for dinner last night?

Where are your scale and calendar located? Have you seen your doctor since you were discharged

from the hospital? Do you have all of your medications? How do you set

your pills up every day? Were there any appointments that kept you from taking

any of your pills?

Enhancing Understanding in the

Patient Education Process

Enhanced Understanding in the Patient Education Process

Redesign the patient education process to improve patient/family or caregiver understanding of self care: Identify the appropriate family or caregivers Involve right learners in all critical education Identify how the patient and family or

caregiver learn best Redesign written material Redesign teaching methods

Enhanced Teaching andLearning Redesign patient teaching material: During acute care hospitalizations for HF, only

essential education is recommended• Reinforce within 1-2 weeks after discharge• Continue for 3-6 months

Adams, KF et al: HFSA 2006 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure Vol. 12, No. 1, pg 61 February 2006

Intervention:Patient Education Material

Key “small tests of change”” Reviewed content of educational materials

utilizing health literacy concepts. Outpatient Heart Failure class utilized as

focus group for content. Family member on team, along with her

siblings, reviewed content for understanding Health Literacy.

Keys to Success Utilizing Health Care Literacy Concepts

On all written materials, matched terminology to what we said in class.

Used term Heart Failure as opposed to Congestive Heart Failure or Chronic HF

Removed ranges Increased font size Added more white space

Keys to Success with Health Literacy

Use universal health literacy communications principles to redesign written teaching materials:

User-friendly written materials use:• Simple words (1-2 syllables)• Short sentences (4-6 words)• Short paragraphs (2-3 sentences)• No medical jargon• Headings and bullets• Highlighted or circled key information

Heart Failure Magnet

Warning Signs and SymptomsHeart Failure Zones

EVERY DAY

Every day: Weigh yourself in the morning before breakfast and write it

down. Take your medicine the way you should. Check for swelling in your feet, ankles, legs and stomach Eat low salt food Balance activity and rest periods

Which Heart Failure Zone are you today? Green, Yellow or Red

GREEN ZONE

All Clear-This zone is your goal Your symptoms are under control You have:

No shortness of breath No weight gain more than 2 pounds (it may change 1 or 2 pounds some days) No swelling of your feet, ankles, legs or stomach No chest pain

YELLOW ZONE

Caution: This zone is a warning Call your doctor’s office if:

You have a weight gain of 3 pounds in 1 day or a weight gain of 5 pounds or more in 1 week More shortness of breath More swelling of your feet, ankles, legs, or stomach Feeling more tired. No energy Dry hacky cough Dizziness Feeling uneasy, you know something is not right It is harder for you to breathe when lying down. You are

needing to sleep sitting up in a chair

RED ZONE

Emergency Go to the emergency room or call 911 if you have any of the following:

Struggling to breathe. Unrelieved shortness of breath while sitting still

Have chest pain Have confusion or can’t think clearly

7/12/2006

Heart Failure HandoutHeart Failure

Heart failure means your heart is not pumping well. Symptoms of heart failure may develop over weeks or months. Your heart becomes weaker over time and not able to pump the amount of blood your body needs. Over time your heart may enlarge or get bigger.

Your heart When you have heart failure, it does not mean that your heart has stopped beating. Your heart keeps working, but it can’t keep up with what your body needs for blood and oxygen. Your heart is not able to pump as forcefully or as hard as it should to move the blood to all parts of your body. Heart failure can get worse if it is not treated. Do what your doctor tells you to do. Make healthy choices to feel better.

Changes that can happen when you have heart failure

Blood backs up in your veins Your body holds on to extra fluid Fluid builds up, causing swelling

in feet, ankles, legs or stomach This build up is called edema

Fluid builds up in your lungs This is called congestion

Your body does not get enough blood, food or oxygen

Signs of heart failure

Shortness of breath Weight gain from fluid build up Swelling in feet, ankles, legs or

stomach

Feeling more tired. No energy Dry hacky cough It’s harder for you to breathe

when lying down

Some causes of heart failure

Heart attack damage to your heart muscle

Blockages in the heart’s arteries which doesn’t let enough blood flow to the heart

High blood pressure

Heart valve problems Cardiomyopathy Infection of the heart or heart

valves

Ejection Fraction One measurement your doctor may use to see how well your heart is working

is called ejection fraction or EF The ejection fraction (EF) is the amount of blood your heart pumps with each

heart beat The normal EF of the pumping heart is 50% to 60% Heart failure may happen if the EF is less than 40%

Treatment for heart failure Eat less salt and salty type foods Take medicines to strengthen your heart and water pills to help your body

get rid of extra fluid Balance your activity with rest. Be as active as you can each day, but take rest periods also Do not smoke

Medicines you might take Diuretic “water pills”- these help your body get rid of extra fluid Beta blocker- lowers blood pressure, slows your heart rate Ace Inhibitor-decreases the work for your heart, lowers blood pressure Digoxin-helps your heart pump better

Things for you to do to feel better each day Follow the guidelines on the St. Luke’s Heart Failure Zone paper Check yourself each day-Which heart failure zone are you today? Watch for warning signs and symptoms, call your doctor if you are in the

yellow zone. Catch the signs early, rather than late Do not eat foods high in salt Do what your doctor tells you to

To learn more about heart failure Attend St. Luke’s FREE heart failure class Phone (319) 369-7736 for more information Visit the following web sites

www.americanheart.org American Heart Association www.abouthf.org Heart Failure Society of America www.heartfailure.org Heart Failure Online

Adapted from American Heart Association 7/2006

Diet InformationReducing Sodium in Your Diet

Why do I need less sodium? Restricting sodium in your diet will help keep you from gaining “water weight,” also called edema. This will also help you control blood pressure. How much sodium do I need? This depends on your medical needs. Limiting sodium to 2000- 3000mg of sodium per day are common restrictions. Ask your doctor if you are unsure how much sodium you need. What should I do first?

Do not add salt to your foods. Salt is very high in sodium. One teaspoon of salt has 2000mg sodium. Start with fresh foods and cook your foods without adding salt. Do not eat foods with salt toppings that you can see.

What foods should I not eat?

Breads and crackers with salt toppings you can see Vegetable juice and tomato juice Cheese spreads and dips; leave cheese off of your sandwiches Ham, deli ham, hot dogs, sausage, bacon Choose frozen dinners with less than 600mg sodium per package. Read labels. Almost all fast food is high in sodium. Choose foods without breading, pickles, cheese or sauces Canned or packaged foods such as soups or noodle mixes Snack chips, pickles, olives, salted nuts

What should I eat and drink at my meals? Try these sample menus for ideas: Breakfast -1 cup Shredded Wheat, banana, 1 cup milk, 2 slices whole wheat bread, jelly, margarine Lunch – Sliced roast beef on bun, 2 tsp mayonnaise, lettuce & sliced tomatoes, fresh melon, cooked or raw carrots, 1 cup milk. Supper – Green salad, 1 TBSP dressing, skinless chicken breast, small baked potato with 1 tsp margarine, frozen mixed vegetables without adding salt, dinner roll, ½ cup sherbet, 1 cup milk. Snack – vanilla wafers or dish of canned fruit or a fresh apple. What else can I do to get more information about eating healthier? It is hard to change the foods you eat. Learning about low sodium eating can be difficult. If you have questions or would like more help in making changes please call a St. Luke’s Dietitian. Workshops are held at St. Luke’s every other month on Saturdays to give people help with controlling Heart Failure. Please call St. Luke’s Cardiac Rehab Department to find the date of the next workshop. This is a FREE class that includes helpful tips on following a low sodium diet. If you need help shopping for reduced sodium food choices, local grocery stores may also give information.

6/2006

St. Luke’s Dietitian: 369-8085 St. Luke’s Heart Failure Workshop 369-7736

On-Line Discharge Instruction

Evaluation of New Patient Education Material

Results from 15 follow-up phone calls: “Information very helpful.” Able to state where information was and

reported that they were referring to it. Understood content. Successfully answered teach back questions

related to “water pill,” diet and weight. Improvement opportunity – patients were often

unclear when they had multiple physicians which one to call for the symptoms (magnet revised).

Enhanced Teaching and Learning

Redesign patient teaching: Stop and check for understanding using Teach

Back after teaching each segment of the information

If there is a gap, review again Another way to close the loop

Redesign Patient Teaching

Slow down when speaking to the patient and family and break messages into short statements

Use plain language, breaking content into short statements

Segment education to allow for mastery

Enhanced Teaching and Learning Utilizing “Teach Back” Explain needed information to the patient or family

caregiver. Ask in a non-shaming way for the individual to explain in

his or her own words what was understood. Example: “I want to be sure that I did a good job of

teaching you today about how to stay safe after you go home. Could you please tell me in your own words the reasons you should call the doctor?”

Return demonstration or show back

Teach Back Questions

What is the name of your water pill? What weight gain should you report to your

doctor? What foods should you avoid? Do you know what symptoms to report to

your doctor?

Enhanced Teaching and Learning

Use Teach Back daily In the hospital During home visits and follow-up phone calls To assess the patients’ and family caregivers’

understanding of discharge instructions and ability to do self-care

To close understanding gaps between: Caregivers and patients Professional caregivers and family caregivers

Teach Back Success

Percent of time patients can teach back 90% or more of content taught related to the transition to home utilizing the four questions related to self management of heart failure

Stop and check for understanding using Teach Back after teaching each segment of information

Assess patient’s, family’s or caregiver’s ability and confidence

Improving Teach Back Results

88% 89%85%

96%

90%86%

95%93%

88%

96%

100%93%

86%83%

93% 92%

98%95%

75%

83%84%84% 82%82%82%

80% 80%

86% 85% 86%84%

67%

83%

92%

100%93%

97%97%

73%

78%

91%89%

100% 100%94%

100%100%96%

60%

65%

70%75%

80%

85%

90%95%

100%

Aug

06

Oct

06

Dec

06

Feb

07

Apr-0

7

Jun-

07

Aug-

07

Oct

-07

Dec

-07

Feb-

08

Apr-0

8

Jun-

08

Aug-

08

Oct

-08

APN VNA

Staff Competency Validation for Teachback

Methodology The learning station will use discussion, role

playing and patient teaching scenarios to help RN’s communicate effectively to patient/family.

Staff Competency Validation for Teachback

Objectives – Each participant will be able to:1. Define health literacy

2. Learn clear communication strategies

3. Define plain language

4. Learn and utilize the “teach back” method in a shame-free way

Staff Competency Validation for Teachback Each participant will participate in a role-play providing

education to a patient. The following will be assessed: Ability to do teach back in a shame-free way; tone is positive Utilizes plain language for explanations Does not ask patient, “Do you understand?” Uses statements such as “I want to make sure I explained

everything clearly to you.” “Can you please explain it back to me in your own words?” Or, as an example, “I want to make sure I did a good job explaining this to you because it can be very confusing. Can you tell me what changes we decided to make and how you will take your medicine now?”

If needed, participant will clarify and reinforce the explanation to improve patient understanding.

Patient and Family Centered Transition Communication

Patient-Centered Transition Communication Provide next caregiver customized real-time information:

What to expect at home Easy to read self-care instructions Reasons to call for help Number to call for emergent and non-emergent needs and questions

Share patient education materials and education processes across all care settings

Physicians, home care and other involved clinicians transmit information at time of discharge

Include anticipated, important next steps in the transition, including concerns about the patients

Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status

Ask receiving care teams for their preferred format, mode of communication and specific information needs about the patient’s functional status

Continually improve by aggregating the experience of patients, families, and caregivers and designing improvements

Heart Failure Zones

EVERY DAY

Every day: Weigh yourself in the morning before breakfast and write it

down. Take your medicine the way you should. Check for swelling in your feet, ankles, legs and stomach Eat low salt food Balance activity and rest periods

Which Heart Failure Zone are you today? Green, Yellow or Red

GREEN ZONE

All Clear-This zone is your goal Your symptoms are under control You have:

No shortness of breath No weight gain more than 2 pounds (it may change 1 or 2 pounds some days) No swelling of your feet, ankles, legs or stomach No chest pain

YELLOW ZONE

Caution: This zone is a warning Call your doctor’s office if:

You have a weight gain of 3 pounds in 1 day or a weight gain of 5 pounds or more in 1 week More shortness of breath More swelling of your feet, ankles, legs, or stomach Feeling more tired. No energy Dry hacky cough Dizziness Feeling uneasy, you know something is not right It is harder for you to breathe when lying down. You are

needing to sleep sitting up in a chair

RED ZONE

Emergency Go to the emergency room or call 911 if you have any of the following:

Struggling to breathe. Unrelieved shortness of breath while sitting still

Have chest pain Have confusion or can’t think clearly

7/12/2006

Example of Class Calendar

St. Luke’s Heart Failure Continuum

Teach back in hospital using new teaching material Standardized HF on-line discharge instructions Home Care complimentary visit 24 to 48 hours post

discharge – use teach back again Physician office visit within three to five days Advance Practice Nurse follow-up phone call on seventh

day post discharge – teach back repeated Outpatient Heart Failure class – seeing increased

participation Collaboration with cardiology office Heart Failure Clinic

Post Acute Care Follow-Up

Post Acute Care Follow-Up

High risk patients: prior to discharge, schedule a face-to-face follow-up visit (home care visit, care coordination visit, or physician office visit) to occur within 48 hours after discharge

Moderate risk patients: prior to discharge, schedule follow-up phone call within 48 hours and schedule a physician office visit within five days

Post Acute Care Follow-Up

High-risk patients: Patient has been admitted two or more times in the

past year Patient failed “Teach Back” or the patient or family

caregiver has low degree of confidence to carry out self-care at home

Patient and family caregiver have the phone number for questions and concerns

Consider home care or discharge coach

Post Acute Care Follow-Up

Moderate risk patients: Patient has been admitted once in the past

year Patient or family caregiver has moderate

degree of confidence to carry out self-care at home

Prior to discharge, schedule follow-up phone call within 48 hours

Schedule a physician office visit within five days

Intervention: Home Care Visit24-48 Hours Post Discharge

Small test of change October 2006 Education to all Home Care staff Visit 48 hours after discharge Visit outline

Medication Reconciliation Review of diet and foods in-house Teach back on water pill, diet and weight Vital signs

Hardwired process in January 2007

Cost for Heart Failure Program

Home Care visit: $110.00 St. Luke’s covers $58.00; the remainder of $52.00

is absorbed Follow-up phone calls: $10,000 Education material

Magnet: $1.00 Total with handouts: $1,200

Intervention: Nursing Home

Patient education sent with all nursing home patients at discharge.

Educational offerings for the staff conducted in the nursing homes.

Nursing home representative added to our HF Team.

Intervention: Follow-Up Phone Call

Advance Practice Nurse makes follow-up phone call at seven days post-discharge

Standardize questions Results monitored and changes made as

needed based on feedback Results monitored globally and per individual

unit

Intervention: Primary CareFollow-Up Appointment

Worked with Primary Care to assure follow-up visits scheduled 3 to 5 days post discharge

Particularly on high-risk patient for readmission

Intervention: Dietitian Visits

Now mandatory on all HF patients

Discharge Status (Nov 07-Oct 08)

51%

16%

5%

12%

16%

Comp Visit VNA Referral Other Referral Refused Missed

Attending MD During Hospitalization(Nov 07-Oct 08)

49%

23%

8%

20%

Cardiologist Hospitalist Int. Medicine PCP

Patient Satisfaction on Discharge Hand-Off

90%

82%

92%

98%

94%91%

87%

100% 100%100%100%100%100%100%100%98%

100%

95%93%

90%

97%95% 94%

100% 100%100% 100%

77%70%

75%

80%

85%

90%

95%

100%

Aug 06

Nov 06

Feb 07

May-07

Aug-07

Nov-07

Feb-08

May-08

Aug-08

Nov-08

Satisfaction Rate

Heart Failure Readmission Rates*

*Percent of heart failure patients readmitted for exacerbation of their heart failure.

Good

0

18.75

0

11.11

4.76

10.53

0

18.7515.79

7.41

3.85

14

10

4

0

9

4.5 46 5

18

57

0 0

3

034.2

15.7917.39

98.78.3

8.38.57

7.14

14.29

28.57

25

10.21211.54

0

5

10

15

20

25

30

May-

05

Jul-

05

Sep-

05

Nov-

05

Jan-

06

Mar-

06

May-

06

Jul-

06

Sep-

06

Nov-

06

Jan-

07

Mar-

07

May-

07

Jul-

07

Sep-

07

Nov-

07

Jan-

08

Mar-

08

May-

08

Jul-

08

Sep-

08

Nov-

08

Pe

rce

nta

ge

Rate (%) Median

Aug 06 = Implemented use of new patient education materials

Jan 07 = Initiated complimentary visits

Example of Data CollectionCHF PATIENT DI SCHARGE FOLLOW-UP

November, 2008

MR ADMIT DATE DISCHARGE STATUS FOLLOW-UP ATTENDING 40671935 11/30/08 Full VNA Pulmonary – 2 wks Vijay Subramaniam 30667231 11/29/08 Complimentary VNA Cardio NP – 3 days Nurse (Venzon) 30568463 11/28/08 Complimentary VNA Cardio NP – 3 days Nurse (Wagdy) 30483197 11/24/08 Refused Cardio NP – 3 days Nurse (Halawa) 40286687 11/23/08 Refused Cardio – 1 week Stankovich 40019174 11/23/08 Full VNA Cardio NP - 3 days Nurse (Khalil) 65076336 11/22/08 LTCF PCP – PRN MA Nelson 30708540 11/21/08 Complimentary VNA Cardio NP – 3 days Nurse (Rater) 30407309 11/18/08 LTCF Cardio – 4 weeks Khalil 30203923 11/18/08 Complimentary VNA Cardio – 1 week Langager 30306362 11/17/08 Genteva Health PCP – 1 month Stahlbert 30465155 11/14/08 In/Out over weekend Cardio – 1 month MA Nelson 30402953 11/13/08 Home Instead PCP – 1 month Voigts 30448902 11/12/08 Refused Cardio – 4 days Laham 65086081 11/11/08 Complimentary VNA Cardio NP – 3 days Atay 30225726 11/10/08 Full VNA Cardio – 2 weeks Brar 40208610 11/9/08 Complimentary VNA PCP – 5 days J . Lee, ARNP 30203777 11/8/08 LTCF Cardio NP – 5 days Nurse (Muellerleile) 30328305 11/7/08 In/Out over weekend Cardio – 1 weeks Chawla 40903634 11/6/08 St. Luke’s Home Care Cardio NP – 4 days Muellerleile 30480366 11/6/08 Complimentary VNA Cardio – 3 days Chandra (prev sched) 30481665 11/5/08 None scheduled Cardio NP – 5 days Nurse (Payvandi) 30960127 11/4/08 Complimentary VNA Cardio – 2-4 wks McMahon 30344191 11/4/08 Full VNA Dialysis next day Pruchno 31467391 11/3/08 LTCF PCP – 1 week Matt Anderson 30749903 11/2/08 Refused Cardio NP – 4 days Nurse (Veluri) 30408875 11/1/08 LTCF Cardio – 1 month Wagdy

Total = 27

LTCF = 5/27 (19%)

Home = 22/27 (70%)

a) Complimentary visit = 8/22 (36%)

b) VNA services/ Other agency referral = 7/22 (32%)

c) Refused follow up = 4/22 (18%)

d) Miscellaneous (None scheduled) = 3/22 (14%)

Follow-up visit within 3 – 5 days = 14/27 (52%); 14/22 (64%)

( n of 27 = all patients counted; n of 22 all patients minus LTCF)

Ordering the 3 – 5 day visit = Staff nurses, Laham, Atay, J ennifer Lee, Muellerleile

Cardiology handled = 18/27 (67%)

PCP/Specialties handled = 7/27 (26%)

Hospitalists handled = 2/27 (7%)

*Palliative Care = 4/27 (15% of total patients):

Cardiology = 0, PCP = 2/4 (50%), Oncology = 0, Hospitalist = 2/4 (50%)

New Palliative Care referral = 3/4 (75%) Previous Palliative Care referral = 1/4 (25%)

HF Continuum Teach back in hospital using new teaching material Standardized HF on-line discharge instructions Home Care complimentary visit 24 to 48 hours post

discharge – use teach back again Physician office visit within three to five days Advance Practice Nurse follow-up phone call on seventh

day post discharge – teach back repeated Outpatient Heart Failure class – seeing increased

participation Collaboration with cardiology office Heart Failure Clinic

Lessons Learned

Engaged leadership Worked in tandem with our CMS core

measures for HF Took advantage of existing workflows Stories are as important as the data Health literacy: “If they don’t do what we

want, we haven’t given them the right information.” (Vice Admiral Richard Carmona, Former Surgeon General)

Our Work Continues

Working on HF LOS Working in conjunction with Cardiologists, PC

HF Clinic HF Certification from JCAHO Working with Wellmark to get Home Visit as a

covered visit

Our Impact

By: Enhancing the patient assessment process on admission Enhancing patient and family understanding of complex

self-care processes Improving the hand-off of critical information to

caregivers in the next care setting Providing continuity in post acute care follow-up

We can reduce unnecessary readmissions for patients with Heart Failure.