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LOS for heart failure drops with program
Program has 6 months follow-up
A nine-month study at a New York State hospital has shown that a well-planned transitional care program for heart failure patients can result in reduced readmissions, hospitalization costs, mortality rates, and length of stay.1
The intervention group of heart failure patients who were at high risk for rehospitalization had an average length of stay (LOS) of 5.1 days, compared with the comparison group's average LOS of 6.7 days, which suggests the intervention can result in a signifcantly lower LOS, notes Cathleen Daley, MS, RN, the heart failure coach at St. Peter's Cardiac & Vascular Center of St. Peters Hospital in Albany, NY.
Heart failure patients who received the transitional care intervention also had significantly lower costs, with an average cost per patient of $8,122 versus $10,175 for the comparison group. This represents a cost savings of $1,592 per individual hospitalization.
These promising results were due to a well-structured transitional care process that included assessing patients' health literacy as well as improving patient communication, education, and follow-up, she adds.
Here is how the transitional care program works:
Assess patient for readmission risk. "It's difficult to determine which patients are at high risk for readmissions, so we spent three months defining the stratification criterion," Daley says.
They looked at every heart failure patient with this screening tool, and eventually determined that a patient who has even one of these risk factors is more likely to be readmitted to the hospital:
Was the patient admitted to the hospital two or more times in the past year?
Did the patient have any two items within a set of Adhere Cart Criteria?
Did the patient have a heart failure readmission within 30 days?
Was the patient's ejection fraction less than or equal to 30%?
Were there two of the three following comorbidities renal failure, chronic obstructive pulmonary disease (COPD), or anemia?
Was the patient newly diagnosed with heart failure?
"The patient might have met one or multiple of these criteria, but they only needed to meet one to qualify for the program," Daley says.
Screen patient for health literacy. "Once they qualify for the program, they are interviewed by me at the bedside with their family," Daley says. "I screen them for health literacy."
Daley tells the patient that she has a laminated food label they could pretend is for ice cream. She explains that she will ask them about this label because it will help her with the education she'll be doing with them.
"Then I ask them specific questions about the label," she says.
The label is 8.5 by 11 inches and has large type to make it easier for elderly patients to see. Since some patients will be unable to read at all, Daley typically gives them the label and asks if they can see the print OK. If they answer, "No," then she knows they may be illiterate and will need other means of instruction, such as oral or pictures. Other patients might be able to read the label but are unable to comprehend what the numbers and words mean for their diet restrictions.
In both cases, Daley will adjust the heart failure education to accommodate their needs.
"Looking at my population, probably 97% of patients had a health literacy score of zero, and what that means on the score sheet ... is there's a high likelihood of 50% or more of limited health literacy," Daley says. "What you find is that people simply do not understand medical jargon, so you have to bring it down to their level of understanding."
For example, if a nurse or health educator use the word "stool," the patient might think they are speaking about something to sit on and not a bowel movement, she says.
"When I explain salt restriction to a patient with a health literacy of zero, I don't use clinical jargon," Daley explains. "I say, 'You need to cut down on salt because your body thinks your blood pressure is falling; it does not know your heart is weak, so your body starts hanging on to every particle of salt you eat or drink."
Teach patient how to manage his or her heart failure. "We sit down as a family with the patient and their significant others and educate them about the type of heart failure they have and their individual risk factors," Daley says. "We teach them the early signs and symptoms they'll need to report to their physician and the importance of their diet, fluid restrictions, and daily weight monitoring."
The heart failure coach's role also includes making certain the patient has the tools needed to manage his or her care. For instance, Daley obtained grants to provide patients who are visually impaired with talking scales, and those with financial constraints with digital scales.
Daley finds that it's important to explain to patients why they must take certain actions rather than just tell them to do it.
"One of the biggest things in our transitional care program is developing a trusting relationship with patients," she says. "They know they can rely on you to be honest and tell them where they are in their disease process."
Assist with transition to community providers. Most heart failure patients were admitted to the hospital under a cardiologist's care, so it's important to keep patients' community primary care physician (PCP) in the communication loop, Daley says.
"We send PCPs a formal letter in which I tell them that their patients were enrolled in the program and will be followed over the next six months," she adds. "I tell them how it's going and send them the patient's lab data, medication, and other information."
Daley arranges for a cardiac center pharmacist to conduct medication reconciliation for each patient at admission, during hospitalization, and at discharge.
"This is imperative," she says. "If the patient's medications are not correct, then the patient will have difficulty at home."
Also, the program includes home care services for most patients. All of the participating home care agencies were trained by Daley to reinforce the self-care education that is continuous across the continuum.
At eight intervals during the six months post-discharge, Daley calls patients and discusses their diet, fluid restriction, daily weight, how to report early signs and symptoms, and whether their medication needs to be changed.
Daley makes sure patients have her hospital telephone number and that they know they can call her and leave a message at any time. She also assists them with making appointments with their PCP before they leave the hospital and asks them about these appointments at post-discharge calls.
She discusses their current health issues and reinforces their discharge instructions and education.
"I might say, 'You told me about your problem. We discussed it, and so when we hang up you're going to call your health care providers and discuss this with them, and if there's a problem you can get back to me,'" Daley explains. "A lot of our elderly patients have great difficulty in bothering a doctor, and sometimes they just need permission in doing this."
1. Daley CM. A hybrid transitional care program. Crit Pathw Cardiol 2010;9(4):231-234.
Cathleen Daley, MS, RN, Heart Failure Co-Chair at St. Peter's Cardiac & Vascular Center, Albany, NY. Email: email@example.com.