Transcript Heart Failure Improvement Across the Continuum

Heart Failure
Improvement Across
the Continuum
Hospital to Home: Optimizing the Transition
January 2009 Florida Hospital Assoc.
Peg M. Bradke, RN, MA
Director, Heart Care Services
St. Luke’s Hospital, Cedar Rapids, Iowa
February 2006
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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
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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
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Heart Failure Work Group reorganized to
include:
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Home Care representative
Family member of a HF patient
Long-Term Care representative
Physician Clinic representative
These views added new context to our efforts.
Measurement
How 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-B26A3391290EC0AD/0/MIFCHFPercentofCongestiveHeartFailurePatientDischargeswithReadmissionWithin30D
ays.doc
Hospital 30-day (all) readmission rate:
 Patient with HF was readmitted for any reason
For both measures:
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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)
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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 Make
That Will Result in Improvement?
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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 Handoffs
4. Post Hospital Follow-up
Result of the IHI Collaborative
Work on Transitions
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Transforming Care at the Bedside How-to Guide
http://www.ihi.org/NR/rdonlyres/8F0551D1-DCD7-4EE7-BEE07C0DFBB5F6AB/5867/TransitionsHome_HowtoGuide_Final102207.pdf
Enhancing the
Admission
Assessment for PostDischarge Needs
Enhanced Admission Assessment
for Post Discharge Needs
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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 representative
 Family member of a HF patient
 Long-Term Care representative
 Physician Clinic representative
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These views added new context to our efforts.
Sample of White Board
Sample of SBAR Kardex
Allergies:
RESPIRATORY THERAPY:
BACKGROUND
SIGNIFICANT EVENTS THIS HOSPITALIZATION:
CODE STATUS: □ Full □ DNR □ Other:
SITUATION
O2 via _________ @ __________
Oxygen Titration Protocol: Y
N
Keep sats _______________
Trach tube/Size________________
□ Cuffed
□ Fenestrated
Past Medical History:
Advanced Directives:
□ None
□ On Chart
□ Family to Bring
Emergency Contact:
HTN
Diabetes
Arthritis
Renal disease CHF
HHN:
DVT prophylaxis:
Inc Spirometry/C & DB:
Patient Requests/TAKE 5 :
IV ACCESS :
Precautions:
Communication: HOH:R/L; glasses; dentures;
non-English speaking: _____________
SAFETY INTERVENTIONS:
Site D done:_________ due:_________
Cap D done:_________ due: ________
Tbg D done: ________ due: _________
IV fluids:
Family Dynamics/Issues affecting care:
Religion/Culture beliefs affecting care:
TELEMETRY: ____________ Reason: ___________
Labs, Radiology Procedures
Monday:
Blood TXM: ___________ units _________ date
__________ units on hold
Tuesday:
Wednesday:
Special Equipment:
Mode of transport: □ Cart □ Wheelchair
Thursday:
Activity:
Friday:
ISOLATION:
Last Screen _______________
□ VRE
□ MRSA
□ C diff
□ Other
Saturday:
Weight bearing status: _______
Sunday:
Lift Equip:
Daily/Weekly Labs:
Adm date: __________ DIAGNOSIS : ___________________________
Ma
OR: _____________ ADMITTING/PRIMARY: _____________________________
ASSESSMENT
VITALS:
□ Routine
□ Other: ____________
Flu: assessed ________ given ________
Call if: SBP less than ______ greater than _______
Pneumonia: assessed ________ given
Temperature greater than _______ degrees
______
HR greater than _______ or less then _______
Bath:
RR greater than ________
Oxygen SAT less than ______ %
Date
Treatments/Other
ACCUCHECK: □ QID
□ BID
□ Other _________
□ SS ____________ □ Insulin Infusion
I & O:
Yes
No
Weight: □ daily □ weekly
□ other____________
Mental Status: □ Alert □ Oriented □ Confused
□ Combative
□ Forgetful
□ Unresponsive
DIET: □ NPO □ Soft □ Clear Liq □ General
□ Diabetic □ Full Liq □ DAT □ Other ___________
Tube Feeding: Solution: _________________
Per Pump: ___________ ml/hr
RECOMMENDATION
Caregraph focus /Pt goals:
Focus #1: _____________________________
Referrals: □ PT □ OT □ SP language
□ SP swallowing □ Hospice □ ET
□ Cardiac/Pul.Rehab □ Palliative
□ Social Services
EDUCATION/ TEACHBACK
□ Dx Specific: _______________________
□ Falls
□ Blood transfusion
□ Meds: ____________________________
□ CORE Measures
□ Treatments: _______________________
□ Other: ____________________________
DISCHARGE PLANNING:
Bolus ___________ ml every _____________
Flush ___________ ml every _____________
Check Residual ________________
□ Salem --# 16/ #18
□ Levine □ Dobb-Hoff
□ PEG
Elimination:
Bladder: □ BR □ BSC □ Incont
□ Foley: size ______ date placed ______
□ St Cath _________ for PVR ________
Bowel:
LBM ________ □ ostomy
Other tubes:
□ JP □ NG □ CT □ Other ________
Name:__________________________________________
CORE Measures: HF, AMI, SCIP, Pnem
Other:
Room #: ___________________
Communication
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Daily discharge huddle at 10:00 AM
Bedside reporting
Both opportunities to review plan for day and
anticipate discharge needs
Reconcile Medications Upon
Admission
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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
Chart Review Tool
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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?
Interview Questions Asked to Patients/
Caregiver Readmitted With Heart Failure
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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
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Redesign the patient education process to
improve patient/family or caregiver
understanding of self care:
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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 and
Learning
Redesign patient teaching material:
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During acute care hospitalizations for HF, only
essential education is recommended
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Reinforce within 1-2 weeks after discharge
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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
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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
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Use universal health literacy communications
principles to redesign written teaching
materials:
User-friendly written materials use:
• Simple words (1-2 syllables)
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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 Symptoms
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
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
YELLOW ZONE
 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
7/12/2006
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
Heart Failure Handout
Heart 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.
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
Signs of heart failure
 Shortness of breath
 Weight gain from fluid build up
 Swelling in feet, ankles, legs or
stomach
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
 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
Your heart
 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
Ejection Fraction
 Fluid builds up in your lungs
This is called congestion
 Your body does not get enough
blood, food or oxygen
 Feeling more tired. No energy
 Dry hacky cough
 It’s harder for you to breathe
when lying down
 Heart valve problems
 Cardiomyopathy
 Infection of the heart or heart
valves
 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
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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
www.abouthf.org
www.heartfailure.org
Adapted from American Heart Association 7/2006
American Heart Association
Heart Failure Society of America
Heart Failure Online
Diet Information
Reducing 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?
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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?
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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.
St. Luke’s Dietitian:
St. Luke’s Heart Failure Workshop
6/2006
369-8085
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
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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
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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
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Use Teach Back daily
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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:
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Caregivers and patients
Professional caregivers and family caregivers
Teach Back Success
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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
75%
65%
APN
VNA
Oct-08
Aug-08
Jun-08
Apr-08
Feb 07
Dec 06
Oct 06
Aug 06
60%
Feb-08
67%
Dec-07
75%
70%
Oct-07
80%
Aug-07
85%
Jun-07
95%
90%
Apr-07
100%
100% 100% 100%
100%
100% 100%97%97%
96%
93%94%
93%
93%
92%
91%
89%
98%
86%
96%83% 95%
96%
95%
93%
92%
90%
78% 88%
89%
86% 85% 86%
88%
86%
84%
85%
84% 84% 83%
82%83%
82%82% 73%
80% 80%
Staff Competency Validation
for Teachback
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Methodology
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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
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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
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Each participant will participate in a role-play providing
education to a patient. The following will be assessed:
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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
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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
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
YELLOW ZONE
 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
7/12/2006
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
Example of Class Calendar
St. Luke’s Heart Failure
Continuum
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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
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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:
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Patient has been admitted two or more times in the
past year
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Patient failed “Teach Back” or the patient or family
caregiver has low degree of confidence to carry out
self-care at home
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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:
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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
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Prior to discharge, schedule follow-up phone call
within 48 hours
Schedule a physician office visit within five days
Intervention: Home Care Visit
24-48 Hours Post Discharge
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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
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Home Care visit: $110.00
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St. Luke’s covers $58.00; the remainder of $52.00
is absorbed
Follow-up phone calls: $10,000
Education material
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Magnet: $1.00
Total with handouts: $1,200
Intervention: Nursing Home
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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
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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 Care
Follow-Up Appointment


Worked with Primary Care to assure followup 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)
16%
12%
51%
5%
16%
Comp Visit
VNA Referral
Other Referral
Refused
Missed
Attending MD During Hospitalization
(Nov 07-Oct 08)
20%
8%
49%
23%
Cardiologist
Hospitalist
Int. Medicine
PCP
Patient Satisfaction on Discharge
Hand-Off
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
100%
100%
98%
97% 98%
95% 94%94%
95%
90%
93%
92%
91%
90%
90%
85%
87%
80%
82%
75%
77%
70%
g
Au
06
No
6
v0
Fe
7
b0
M
7
-y 0
a
07
g
Au
7
-0
v
No
F
08
eb
Satisfaction Rate
M
8
-y 0
a
08
g
Au
N
8
-0
v
o
Heart Failure Readmission Rates*
Good
30
28.57
25
Percentage
25
20
15
10
5
0
Aug 06 = Implemented
use of new patient
education materials
Jan 07 = Initiated
complimentary visits
18
17.3918.75
15.79
15.79
14.29
11.5412 14
11.11 10.53
10.210 8.3
9
9
8.3 8.7
7.41 8.57
7.14
7
6
4.76
4.5 4 5 5 4.2
4
3.85
3
3
00 0
0
0
0
0
18.75
Rate (%)
Median
*Percent of heart failure patients readmitted for exacerbation of their heart failure.
Example of Data Collection
CHF PATIENT DISCHARGE FOLLOW-UP
November, 2008
MR
40671935
30667231
30568463
30483197
40286687
40019174
65076336
30708540
30407309
30203923
30306362
30465155
30402953
30448902
65086081
30225726
40208610
30203777
30328305
40903634
30480366
30481665
30960127
30344191
31467391
30749903
30408875
ADMIT DATE
11/30/08
11/29/08
11/28/08
11/24/08
11/23/08
11/23/08
11/22/08
11/21/08
11/18/08
11/18/08
11/17/08
11/14/08
11/13/08
11/12/08
11/11/08
11/10/08
11/9/08
11/8/08
11/7/08
11/6/08
11/6/08
11/5/08
11/4/08
11/4/08
11/3/08
11/2/08
11/1/08
DISCHARGE STATUS
Full VNA
Complimentary VNA
Complimentary VNA
Refused
Refused
Full VNA
LTCF
Complimentary VNA
LTCF
Complimentary VNA
Genteva Health
In/Out over weekend
Home Instead
Refused
Complimentary VNA
Full VNA
Complimentary VNA
LTCF
In/Out over weekend
St. Luke’s Home Care
Complimentary VNA
None scheduled
Complimentary VNA
Full VNA
LTCF
Refused
LTCF
FOLLOW-UP
Pulmonary – 2 wks
Cardio NP – 3 days
Cardio NP – 3 days
Cardio NP – 3 days
Cardio – 1 week
Cardio NP - 3 days
PCP – PRN
Cardio NP – 3 days
Cardio – 4 weeks
Cardio – 1 week
PCP – 1 month
Cardio – 1 month
PCP – 1 month
Cardio – 4 days
Cardio NP – 3 days
Cardio – 2 weeks
PCP – 5 days
Cardio NP – 5 days
Cardio – 1 weeks
Cardio NP – 4 days
Cardio – 3 days
Cardio NP – 5 days
Cardio – 2-4 wks
Dialysis next day
PCP – 1 week
Cardio NP – 4 days
Cardio – 1 month
ATTENDING
Vijay Subramaniam
Nurse (Venzon)
Nurse (Wagdy)
Nurse (Halawa)
Stankovich
Nurse (Khalil)
MA Nelson
Nurse (Rater)
Khalil
Langager
Stahlbert
MA Nelson
Voigts
Laham
Atay
Brar
J. Lee, ARNP
Nurse (Muellerleile)
Chawla
Muellerleile
Chandra (prev sched)
Nurse (Payvandi)
McMahon
Pruchno
Matt Anderson
Nurse (Veluri)
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%)

Ordering the 3 – 5 day visit = Staff nurses, Laham, Atay, Jennifer 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):
( n of 27 = all patients counted; n of 22 all patients minus LTCF)
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.