TELEPHONE SUPPORT TO REDUCE READMISSIONS IN OLDER ADULTS WITH CONGESTIVE HEART FAILURE
Background: CHF is the number one discharge diagnosis among patients 65 years and older, affecting 5.8 million people in the United States and an estimated 23 million people worldwide. CHF totals (1) million yearly admissions and 27% are readmitted within 30 days of discharge. Re-hospitalizations are associated with high mortality rates and estimated at $13,000 per patient, contributing to the annual $33.7 billion dollar cost. Beginning in 2012, The Centers for Medicaid and Medicare initiated the Hospital Readmission Reduction Program, where 30-day readmissions would no longer be compensated. Patients with CHF and frequently their caretakers are overwhelmed due to lack of knowledge and skills regarding self-care management. In addition, the variations between acute care therapy and homecare regimens contribute to readmissions. Extensive research on CHF reinforces the use of f/u calls as the intervention of choice to prevent early readmissions as evidenced by a reduction of 30%. In fact, benchmark data retrieved from past research confirms a clinical and statistical significance when using STS. In the project facility, the average readmission rate for CHF patients is 8%.
Practice Change: The purpose of this evidence-based practice project is to reduce the number of CHF patient readmissions by 20%. The Iowa Model of Evidence Based Practice will be used as a framework for the project. CHF patients recently discharged will be identified in collaboration with the hospital’s Health Information Management and Quality Assurance /Improvement Departments. Using the Valley Care Health System Education Heart Failure call back form, patients will be contacted post discharge at 24-48H, day 10-15, day 20-25, and day 30-31. During each call, data collection will focus on clinical measurements including daily weight and symptoms of CHF exacerbation along with diet modification and medication compliance. Concurrently, symptomatic patients will be referred to their PCP for evaluation. At the conclusion of this project, a chart review will be conducted to calculate the percentage readmissions and an internal evaluation performed to assist in creating a job description for the “Nurse Navigator,” hired to sustain the CHF project.
Results: In progress: It is anticipated that there will be a 20% reduction in the number of readmissions following the use of discharge follow-up calls.
Conclusion/Implications: If shown to be effective in minimizing readmissions, telephone follow-up should become standard procedure in the setting. CHF patients, who are educated about their disease process, compliant with medications, and participate in self-care management typically, have improved outcomes. Since patient access to primary care is challenging due to provider shortage, Advanced Practice Nurses play an integral role in the health care system to enhance CHF patient outcomes and reduce the healthcare costs associated with this patient population.