Heart to Home, Sooner, Safer, and Longer: Nurse/Patient Collaboration to Reduce Readmissions for Heart Failure Patients

Purpose:
Our aim is to reduce heart failure all-cause readmissions by 25% by August 1, 2010. We will demonstrate that the highly engaged staff who provides patients with nurse-driven, reliable processes contributes to the reduction in readmissions and improved patient perceptions of hospitalization.

Significance:
Avoidable hospital readmissions affect 1 in 5 patients, & accounts for $17.4 billion of the current $102.6 billion Medicare budget. Unreliable execution in the patient's transition from in to out-patient status negatively affects pt. health and well-being, resulting in readmissions to the hospital.

Strategy and Implementation:
Commencing with the in-patient admission, and continuing through the transition to out-patient, orchestrated interventions engage patients, families, and care-givers to be better self-managers. RN's initiate, implement, monitor and maintain measures that are designed to shepherd patients from hospitalization through their transitions home. Centralizing the dispersed HF patient population, identifying and closing gaps in planning for the transition, identifying and reducing failures in communication, and reducing delays in scheduling post-discharge care all contribute to reducing readmissions. Reliable interventions included: enhanced assessment of teaching and learning, early identification of post-discharge needs, standardized protocols for communication at discharge, pre-discharge appointment setting, timely post-acute follow-up, accountability for the patient's transition, and maintaining continuity in patients' medical care post-discharge.

Evaluation:
The ICD-9-CM codes defined the Heart Failure patient cohort.By May 2010, readmissions were better than target for 3 months. Patient satisfaction was measured by Press-Ganey surveys. Patient satisfaction consistently 99%. Staff engagement measured through the NDNQI PES, and above the 75th percentile.

Implications for Practice:
Orchestrated transitions and reliable communication significantly impacts a patient's quality of life and perceptions of care. Poorly executed patient transitions often negatively impact the likelihood of the patient to self-manage resulting in avoidable, costly readmissions and poor satisfaction.