Innovate Congestive Heart Failure Program: Decreasing 30-Day Readmissions

Purpose:
The purpose of the innovative Congestive Heart Failure (CHF) program is to create a nurse led collaborative comprehensive network of patient care between inpatient and outpatient settings to reduce readmissions and improve quality of care.

Relevance/Significance:
Learn about how an innovative Congestive Heart Failure Program lead by a Nurse Navigator and an APRN decreased 30-day readmission rates by translating continual practice improvements into viable solutions that advance clinical patient care. Gain insight into the CHF Program's best practices that include group appointments, group education, and comprehensive collaboration with inpatient and outpatient resources to create easier access to CHF Healthcare.

Strategy and Implementation:
An RN CHF Navigator and an APRN coordinate care in the inpatient and outpatient setting. They standardize inpatient education including individualized education at the patient's bedside and group education for multiple inpatients and their care providers. To support the outpatient, the APN and Navigator provide telephone follow-up, support, and group visits in the CHF clinic. The outpatient CHF clinic group visits provide a community for patients with education, medication assessment and emotional needs. The APRN and Navigator foster interdisciplinary collaboration between primary care physicians and cardiologists as well as other disciplines including pharmacy, physical therapy, dietary, spiritual care, and cardiac rehab to meet the patient's needs. Hospital and community resources were implemented to create easier access to CHF healthcare through collaborating with home health care, extended care facilities, hospital based infusion center, and support groups.

Evaluation:
This compressive CHF program has increased the quality of care. In 2014, 70 patients participated in the program. Three of these patients had a 30 day readmission, however only 1 was related to CHF.

Implications for Practice:
Decreasing CHF 30-Day readmissions is a result of providing a nurse led robust comprehensive inpatient and outpatient CHF program. Future implications for nursing practice include replicating the current inpatient and outpatient practices at all 22 acute care sites in the system.