Download Best Practice: Heart Failure - Mercy Medical Center

Best Practice: Heart Failure
Heart Failure Protocols
Connie Vierkant, RN, BSN
Community Health Coach
Mercy Family Medicine Residency
Objectives:
‘Briefly review the history of Trinity’s
Heart Failure Iniative
‘Discuss how the LACE Scoring Tool
determines Patient Risk of Readmission
‘Discuss how Heart Failure Care Protocols
guide care from hospitalization to the
Primary Care setting
Where it all began……
‘ January 2011 – Patients with heart failure would
be identified within 24 hours of admission.
‘ March 2011 – Case Manager coverage on
weekends.
‘ May 2011 – Heart failure patients now referred to
Mercy Home Care. LACE scale now being
utilized.
‘ October 2011 – Follow-up appointments
scheduled with PCP within 7 days of discharge.
‘ June 2012 -Electronic Health Record (NextGen)
implemented at Forest Park Clinic
Modified LACE Scoring Tool
‘How can patients who are at high risk of
being readmitted be identified so that
further hospital admissions may be avoided
and enhance the discharge to home
process?
‘One strategy is the use of a predictive
model that flags patients at risk due to their
chronic heart failure.
Modified LACE Tool
3
0
6
0
9
25
LACE Score and Primary Care
‘So how does this score affect the care of
the chronic heart failure patient in your
office?
Ultimate Goal of Initiative
‘ Reduce the number of readmissions within 30
days for patients with chronic heart failure by
increasing in-patient education, telephone followup within 24-48 hours post-discharge, increasing
home care visits utilizing Mercy Home Care and
County Public Health referrals and increased
follow-up with the PCP within 3 days for LACE
score of 10 or greater, 7 days for a score of less
than 10, in 14 and 21 days after leaving the
hospital.
Initiative goals continued:
‘ Improve the transition of patient care by
improving the communication of information
between the Hospitalist/Cardiologist and the
PCP.
‘ Discharge notes must be dictated within 24 hours
of discharge.
‘ Implementation of Electronic Health Record
throughout the Mercy system so that PCP clinics
may access hospital record information.
What’s my role in caring for the
Heart Failure patient?
‘ Encourage patients to follow their discharge
instructions: Take their medications as
prescribed, restrict salt intake, restrict fluid
intake, pace their activity and rest with legs
elevated when tires, and weigh daily and
record.
‘ Encourage patients to review their heart failure
book given in hospital.
‘ Encourage patients to keep their 3 follow-up
appointments set at discharge.
‘ Excellent medication reconciliation each and
every clinic visit.
Questions??