COACH for Heart Failure
Handout (1.1 MB)
To decrease heart failure hospital readmissions and improve patient outcomes through an innovative program to assist in care coordination using evidence-based practice and an interprofessional approach to patient-centered care.
Relevance/Significance:
Heart Failure affects nearly six million people in the United States, with approximately one million being admitted to the hospital each year. Of the people admitted, approximately 27% are readmitted within 30 days. For the past several years, the readmission rate for heart failure patients has been high. Opportunities for improving the coordination of care for heart failure patients were identified through a team effort and disseminated throughout the network to improve patient care.
Strategy and Implementation:
The heart failure initiative adheres to the Lean Six Sigma principles of focusing on the patient, flexibility, focus on the problem, improve the process flow, and keep it simple. A small team was initially formed to develop a goal tree to determine necessary actions needed to help reduce heart failure readmissions. Patient engagement, education, improved collaboration across the continuum and improved discharge planning were just a few objectives identified. A heart failure committee was already in place, but reassessed for key players. Weekly meetings were established to focus on goals and barriers encountered. Plans for delivering care, education and providing needed resources were developed. The program piloted on one hospital unit initially and was then disseminated throughout the system. Weekly meetings changed locations from the hospital, to homecare, to the network offices in order to engage participants throughout the network.
Evaluation:
The initiative resulted in a 25% reduction in heart failure readmissions from 2011-2014. Our hospital went from one of the worst performing hospitals in our organization to one of the top 10 hospitals that improved from baseline. Other successes include more standardized care, consistent education across the continuum, increased utilization of palliative medicine, homecare, and tele-health.
Implications for Practice:
The concepts of this program are now in development for chronic obstructive pulmonary disease within our health system. It has the potential to improve the management of other chronic diseases due to its evidence-based underpinnings of education, support, and ensuring needed resources for success.