Heart Failure "Transition of Care" Model

Purpose:
MWH's nurse-led HF Team formed a “transition of care” taskforce in 2010 to examine methods to reduce our 30-day HF readmission rate. The goal was to develop a multidisciplinary approach to HF care including a coordinated process for transition of care from the inpatient to outpatient setting.

Significance:
HF is a national health problem affecting 5 million Americans and costing $33 billion a year. High costs result from frequent hospitalizations with national readmission rates of 25% within 30 days and 50% within 6 months. MWH's readmission rates were well above the national average.

Strategy and Implementation:
Our strategy was to provide tools, support and guidance to close the gap between acute and chronic care, while encouraging patient participation with self-care. We implemented a multidisciplinary approach that includes dietary, palliative, rehab, and a HF Navigator who provides patient education, identifies barriers to self-care and coordinates transitions. Patient education tools were revised for consistency throughout the continuum of care, and “teachback” was incorporated in the nursing care plan. Our telephonic nurse program developed a “transition coach” process consisting of post-discharge calls focused on patient assessment and education. We collaborated with our HF Clinic and community PCPs to ensure early follow-up after discharge. We identified opportunities with our local skilled nursing facilities and provided their staff HF education. Lastly, we developed a free cardiopulmonary rehab program for HF patients who would otherwise not have the benefit of monitored exercise.

Evaluation:
We determined success of this project by analyzing HF all-cause readmission rates, defined as a readmission within 30 days for any reason, following an index admission of HF. We achieved a 38.7% reduction in MWH's 30-day HF readmission rates, and have sustained that success since Nov 2010.

Implications for Practice:
Nursing envisioned, implemented and continues to lead the HF "transition of care” model that provides patient-centered care across the continuum. This process has been incorporated by other teams in our hospital to reduce readmissions and viewed as "best practice" by other organizations.