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HF management program decreases readmissions
Clinic, phone, and remote monitoring used
The first year after Piedmont Hospital in Atlanta implemented a Heart Failure Resource Center that provides care coordination for patients discharged with heart failure, the 30-day rehospitalization rate for heart failure patients in the program decreased from 4.6% to 1.6% when compared to heart failure patients treated at Piedmont and not in the program. At the same time, the 90-day readmission rate dropped from10.4% to 2.9% for patients in the program when compared to patients treated at Piedmont Hospital for heart failure who did not receive the interventions and were readmitted.
Nurse practitioners function as clinical care coordinators and consult physicians if needed. They meet with patients at the clinic on a regular basis and consult with them on the telephone to answer questions and help them manage symptoms between visits. About 70 patients who are at high risk for readmission, who need extra help in self-managing their condition, or who live outside the Atlanta area use a remote tele-monitoring system that plugs into their home telephone line and alert the nurses when a patient's condition deteriorates.
The nurse practitioners follow evidence-based protocols approved by the program's medical directors and participate in multidisciplinary weekly rounds to evaluate and discuss new patients. The team includes a clinical nurse specialist, staff nurses, a clinical pharmacist, a cardiac rehab specialist, a clinical case manager, the program manager, and medical directors.
"We teach the patients from day one that we do not provide emergency care. We teach them to recognize heart failure symptoms earlier so we can help them avoid them having an acute episode of heart failure and save a trip to the hospital," says Julie Webster, NP, nurse practitioner and clinical manager at the facility.
Most of the patients in the program are referred by their physicians after they are hospitalized with heart failure. The initial clinic visit takes about two hours and included a comprehensive evaluation and detailed education about heart failure. The nurse practitioners work with the patient to develop a plan of care and to set goals. "We collaborate closely with the patient's cardiologist or other physician. We send all our notes, clinic visit summaries, and treatment to the treating physician," Webster says.
The nurses educate patients about diet and salt intake, exercise, their medication regimen, smoking cessation, and what symptoms indicate that they should call the clinic. They give patients a comprehensive patient education book that the multidisciplinary heart failure treatment team developed for use in the hospital as well as the clinic. "We emphasize how important their medication therapies are and how important it is to be compliant with their treatment plan. If patients are uninsured or self-pay, we can refer them to a social worker who can help them apply for assistance," Webster says.
Most new patients come back to the clinic every two to three weeks for a couple of months. As they learn to manage their condition, they are seen less frequently.
The high-risk patients receive a touch-screen computer, a scale, and a blood pressure cuff they use every day to transmit weight, blood pressure, heart rate, and answers to a series of questions about heart failure symptoms to the advance practice nurses. The clinicians in the program established a threshold for each patient that indicates when their symptoms are getting out of control, Webster says. When patients' weight gain goes beyond the established parameters, blood pressure is elevated, or the patient reports shortness of breath or swelling, the patient's record appears in red on the computer screen at the clinic.
"If patients don't call us, we call him and get more information about the symptoms," Webster says. "Often we can manage over the telephone by modifying the patient's therapy and checking the next day to see how the symptoms have responded. In severe cases, we have the patient come into the clinic for evaluation and treatment, such as IV diuretics. One of our priorities in this program is to keep the patient's condition under control and avoid hospitalization."