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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 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 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 Heart Failure Work Group reorganized to include: 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: 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) 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? 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 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 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 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 Daily discharge huddle at 10:00 AM Bedside reporting Both opportunities to review plan for day and anticipate discharge needs Reconcile Medications Upon Admission 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 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 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 Redesign the patient education process to improve patient/family or caregiver understanding of self care: 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: During acute care hospitalizations for HF, only essential education is recommended • Reinforce within 1-2 weeks after discharge • 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 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 Use universal health literacy communications principles to redesign written teaching materials: User-friendly written materials use: • Simple words (1-2 syllables) • • • • • 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 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? 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? 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 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 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 Use Teach Back daily 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: Caregivers and patients Professional caregivers and family caregivers Teach Back Success 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 Methodology 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 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 Each participant will participate in a role-play providing education to a patient. The following will be assessed: 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 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 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 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: Patient has been admitted two or more times in the past year Patient failed “Teach Back” or the patient or family caregiver has low degree of confidence to carry out self-care at home 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: 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 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 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 Home Care visit: $110.00 St. Luke’s covers $58.00; the remainder of $52.00 is absorbed Follow-up phone calls: $10,000 Education material Magnet: $1.00 Total with handouts: $1,200 Intervention: Nursing Home 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 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.