Original Article
Tailoring Your Heart Failure Project for Success in Rural Areas Martha Vesterlund, MSN, APRN, ANP-C; Bradi Granger, PhD, RN, FAAN; Terry J. Thompson, MD; Chuck Coggin III, MD; Marilyn H. Oermann, PhD, RN, ANEF, FAAN Purpose: The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model. Methods: An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge. Results: Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted. Implications: The IPC was effective in decreasing HF readmissions. Conclusions: These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF. Key words: heart failure readmissions, interdisciplinary plan of care, patient education, quality improvement,
readmissions
H
eart failure (HF) costs the nation $34.4 billion each year1 and is the most common Medicare diagnosis-related group for readmissions.2 The cost burden of HF and threat of no reimbursement from Medicare for HF readmissions have created the need to better manage care of these patients. In low-income and rural areas with lack of financial resources, the growing concern is loss of reimbursement, which might eventually lead to hospital closure and place the community at risk. The Centers for Medicare & Medicaid Services has initiated hospital quality measures, which include publicly reported 30-day readmission rates. Hospitals with high readmission rates can lose up to 3% of their Medicare reimbursement for 2015.3 Medicare payments traditionally were made to hospitals for each patient admission, regardless of the number and frequency of those admissions. With the institution of Author Affiliations: Medical Associates of Central Virginia, Appomattox (Ms Vesterlund); Duke University School of Nursing, Durham, North Carolina (Drs Granger and Oermann); Medical Director Hospitalist Service, Centra Southside Community Hospital, Farmville, Virginia (Dr Thompson); and Medical Associates of Central Virginia, Lynchburg (Dr Coggin). Correspondence: Martha Vesterlund, MSN, APRN, ANP-C, 2429 Purdum Mill Rd, Appomattox, VA 24522 ([email protected]; [email protected]). The authors acknowledge the following persons for their assistance: Julie Thompson, PhD, David Truitte, MD, Heather Bailey, BSN, RN, Dion Tomer, BSN, RN, Amanda Marsh, RN, Frieda Penzer, BSN, RN, Dennis Brown, LMSW, Brandy Earhart, MSN, RN, Kendall Wills Sterling, ELS. There are no disclosures, no conflicts of interest, no monies received for this work. Q Manage Health Care Vol. 24, No. 2, pp. 91–95 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000055 April–June 2015 r Volume 24 r Number 2
readmission penalties, hospitals are now challenged to prevent readmissions to avoid these penalties.4 In areas without many resources outside the hospital, such as rural areas, it is essential for hospitals to address the problem of readmission for HF patients. Unplanned readmissions suggest issues with patient self-management and care transitions from hospital to home that reflect negatively on quality of care.4 Various studies have examined interventions incorporated into the patient’s hospital stay to prevent readmissions and improve quality of care. There are a growing number of studies on interventions for reducing readmission rates for the HF patient population. The majority of studies document the importance of disease management teaching compared with usual discharge teaching for the HF patient population.5-11 As part of this instruction, incorporating the “teach-back” strategy is pivotal in promoting patients’ understanding and avoiding rehospitalization.12 Teach-back is a way to confirm that nurses and other providers have explained to patients what they need to know in a manner that patients understand.13 Educating patients before discharge promotes self-care, decreases readmissions, and helps patients identify problems early once at home.14 Other interventions for improving quality of care for patients with HF and preventing readmissions include a follow-up phone call and appointment within 5 to 7 days with their primary care provider.6,8,10,15,16 Other studies have examined the effects of incorporating multiple interventions into a plan of care for these patients. These studies found improvements in readmission rates from 3% to 18%, with 1 or 2 interventions5–7,10 to 6 total interventions provided for HF patients.8,9,17,18 For example, Bradley et al18 studied the effects of www.qmhcjournal.com
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integrating 6 interventions into the plan of care for patients with HF, which, in turn, improved readmission rates. LOCAL PROBLEM Our nonprofit hospital’s readmission rate for HF patients ranged from 20% to 25% for the years 20092013, above the national average. Patients received general discharge teaching and case management, but there were no strategies in place to ensure follow-up care for these patients. PURPOSE
The purpose of this quality improvement project was to decrease 30-day readmission rates for patients with HF through the development and implementation of a new integrated plan of care (IPC) for these patients. The IPC included 6 interventions: (1) detailed HF education for patients and families; (2) a discharge HF packet; (3) nutrition education; (4) case management; (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge; and (6) a follow-up phone call to each patient within 48 hours postdischarge. The interventions included in the ICP are particularly important for patients in a rural community who may have limited access to resources and education. METHODS Design
The HF project design was a quality improvement study on the effects of an IPC on HF readmissions. All patients admitted under the 291-293 diagnoses codes for HF starting July 15, 2014, to October 31, 2014, received the new IPC and were followed using prospective chart review. Setting
Southside Community Hospital is a not-for-profit, 86bed facility that serves a rural community in Virginia. The unemployment rate for this community is 9.8%, which is above the state average of 5.4%.19 The median household income is significantly below state average ($24 582 vs $61 741).20 Outside sources including primary care physicians are lacking in this area, which, in turn, cause patients to use the emergency department for their primary care. Sample
Inpatient HF patients older than 18 years with a primary diagnosis of acute HF (diastolic or systolic, preserved left ventricular ejection fraction) admitted for acute care at the Southside Community Hospital were included in the project. A total of 61 patients admitted with the diagnosis of HF received the IPC. Patients could speak and understand English. The readmission rates for patients with HF admitted a year prior to and the quarter before implementing the new
www.qmhcjournal.com
plan of care were used as the baseline measure. The project was approved by the university and hospital institutional review boards. Informed consent was not required. Intervention
To better prepare patients for managing their HF at home and to reduce readmission rates, an IPC was developed and implemented for these patients. The IPC included the American Heart Association “Get With the Guidelines” tool kit and a teach-back tool used to implement quality discharge teaching by staff nurses. Nurses provided detailed HF education including medication instructions and care at home including teaching them home survival skills such as symptom recognition (increased dyspnea, weight gain, and edema) and proper treatment of these symptoms. Patients received a discharge packet that included an HF calendar for documentation of their daily weights and the symptom evaluation brochure. These educational materials were available but not used at our hospital until initiation of this project. The packet also included a list of patients’ follow-up appointments and provider telephone contact numbers and dietary limitations. As part of the IPC, patients were referred to the nutrition team and received education about dietary restrictions and a low-sodium and low-fat diet. Patients also were referred to case management. The case manager initiated home health services and skilled nursing facility placement as needed and established a primary care provider for those HF patients without one prior to discharge. The IPC included follow-up appointments with patients’ primary care provider for 5 to 7 days postdischarge and with their cardiologist for 2 weeks after their discharge. These appointments were made for patients during their hospital stay. The telephone numbers for patients’ providers were listed in their discharge packet. Finally, patients received a follow-up phone call from the charge nurse, staff nurse, or nurse practitioner within 48 hours to answer patients’ questions and confirm their follow-up appointments. This follow-up call incorporated the teach-back tool to review patients’ understanding of symptoms and evaluation of further needs. To prepare nurses for teaching patients, a PowerPoint presentation was developed for the nurses to complete at the start of the project. This presentation included a review of HF, education on HF medications, an explanation of teach-back strategies to help nurses evaluate how well patients comprehended their disease management teaching, and other essential areas of teaching about HF. The nurses completed a 15-item preand posttest. The mean percent correct increased from 53% at pretest to 96% at posttest, indicating nurses had learned this content, which is essential for teaching patients and families prior to discharge. Procedures
An administrative data sheet was printed for the medical-surgical unit each day with all HF patients
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
April–June 2015 r Volume 24 r Number 2
admitted during the previous 24 hours; the nurse practitioner or charge nurse rechecked all admissions for the hospital to identify other patients with HF not included on this data sheet. A “call-back” questionnaire was added to the patient’s charts with an identifying sticker that the patient had HF. There was a checkoff box by nursing staff in the hospital Electronic Medical Record (EMR) to verify that HF discharge teaching was completed. Under the same Portal database, case management and nutrition services also checked off their involvement in the patient’s care. A weekly chart review was used to verify that all components of the ICP were implemented and that each component was documented in the EMR. When patients were discharged, whether they received an HF packet at discharge and confirmation that their follow-up appointments were made were written on the call-back questionnaire. Review of the administrative data sheet compared with the patient census revealed patients who were discharged without an HF packet and follow-up appointments made for them. The data were then deidentified by the quality improvement team, and checkoffs were categorized into an Excel spreadsheet. Data were available in the EMR to verify whether the patient was readmitted within 30 days. Data analysis
Patient demographic data were analyzed using descriptive statistics. The readmission rate that was reported prior to the IPC was calculated according to administrative data. Readmission rate was calculated as the number of patients readmitted with HF out of the total number of patients admitted with HF and then multiplied by 100 to get a percentage. The percent change was calculated using the following formula:
( p1 − p2 ) × 100 p2
Fidelity in completing the 6 interventions was conducted for each admission and readmission and was analyzed using cross tabs and the χ 2 test. Relative risk ratio for HF teaching was conducted, and the risk estimate was calculated with a 95% confidence interval. Data were analyzed using IBM SPSS Statistics for Windows, version 22.0. RESULTS Under the diagnostic codes 291, 292, and 293, all patients (n = 61) were eligible for this program and all patients participated. Of the 61 patients, 31 were men, and the mean age was 75.9 years. There were 34 patients with Medicare, 3 with Medicaid, 20 self-pay, and 4 with private insurance. Thirty black, 30 white, and 1 Asian patient participated in the study. Thirty-day readmission rate
The 30-day readmission rate for patients with HF in 2013, prior to the project, was 20.9%. Over a 3-month
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period, 61 patients with HF participated in the project and received the ICP. Of those 61 patients, only 8 (4 women, 4 men) were readmitted within 30 days, a readmission rate of 13.2%. The percent decrease in readmissions was 37.3%, calculated using the following formula: ( p1 − p2 ) p2 × 100. The 13.2% readmission rate was also compared with the hospital’s quarterly readmission rate during the project time period, which was almost the same at 13.1%. In addition to comparing our HF readmissions with the hospital’s 2013 rate, the quarterly results just prior to the beginning of the project were examined; the 2013 rate was consistent with the quarterly results according to administrative data. Of the 6 interventions in the ICP, each patient received all of the interventions except for 17 people who did not have a nutrition consult and 4 who did not receive the HF discharge teaching. None of the interventions were significantly associated with readmission except for HF discharge teaching, which significantly impacted readmission rates. Of the 61 patients, 8 were readmitted. Of these 8 readmissions, 4 patients had not received HF teaching with the updated discharge packets. Those patients who did not receive the teaching were almost 7 times more likely to be readmitted (n = 4 of 8 patients; 50%) than those who received the teaching (n = 4 of 53 patients; 7.5%; P = .007). Of the 8 readmissions, 4 patients had Medicare and 3 were self-pay, and 6 of the 8 readmitted patients were older than 80 years.
DISCUSSION With readmission penalties imposed by the Centers for Medicare & Medicaid Services, all hospitals run the risk of losing much needed reimbursement. Loss of financial compensation threatens hospital closure, which, in turn, would decrease access to health care for the community. In rural areas where care is limited, the risk of losing hospital facilities is worrisome. Having a plan of action at home with instructions on how to manage symptoms, and when to call the primary care provider or cardiologist, helped patients from being readmitted. Literature on preventing readmissions supports follow-up phone calls after hospital discharge.4,5,10,17,18 In this project, patients were telephoned within 48 hours of discharge, educational support was provided, and home services (such as home health) were initiated postdischarge if needed. During this phone call, patients who were unable to fill their prescriptions at discharge, who needed home health services but declined it during hospitalization, and who were using the educational materials provided at discharge were identified. Incorporating home health services for patients with chronic disease has also been supported in other studies.18,21,22 In addition, home health nurses evaluated symptoms for patients at follow-up and at times instructed decompensating
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patients to follow up with their primary care providers or cardiologist sooner. The IPC improved care for these inpatients in this rural community. Improvements in clinical outcomes with using HF multifaceted discharge teaching were effective in preventing readmissions. When compared with patients with HF disease–specific teaching by nursing staff at discharge, the patients who did not receive this education were 7 times more likely to be readmitted. The strategies for HF patients and multidisciplinary team involvement used in this project to prevent readmissions are supported by other studies.17,18,22 Multidisciplinary disease management programs can substantially reduce readmissions for HF.17 In this project, multiple disciplines working together transitioned patients to proper home health services, which, in turn, prevented readmissions. Home health nursing staff further reviewed and supported the interdisciplinary team after discharge using the HF education packet with patients at home to stress the importance of symptom recognition and treatment. Treating their symptoms before they advanced to severe exacerbations enabled patients to remain independent for longer periods of time and manage their disease at home. In geographical areas with limited health care resources, hospitals are under increasing pressure to address the problem of readmission for patients with HF. In low-income areas with a lack of financial resources, the growing concern is loss of reimbursement, which might lead to hospital closure. In areas without many resources outside the hospital, it is essential to have hospital facilities to care for this population. This project’s goal was to encourage self-care at home to prevent HF readmissions in this rural community where sources are scarce outside the hospital system. By using an IPC and incorporating the support of a variety of specialties on the nursing care team, combined with interdisciplinary team involvement, readmission rates fell dramatically. Integrating multifaceted interventions into an IPC specific for a rural, low socioeconomic community demonstrated a commitment by the entire health care team to improve quality of care. In addition, our connection with outpatient services strengthened during this project and the interdisciplinary team established vibrant relationships with patients.23 Limitations
This is not representative of all rural community hospitals throughout the United States. The actual home practices of the patients cannot be determined from this project. Patients’ compliance with medications and diet is a common cause of HF exacerbations that can directly affect readmission. Nurse navigators are not employed by this specific hospital, thus following patients to evaluate compliance with follow-up appointments and medication was not possible. The readmission rates reported could be an underestimation, as HF readmissions outside our health care system could not be accounted for. Further research into disease man-
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agement teaching at discharge and patient noncompliance issues is warranted to fully understand caring for vulnerable populations. CONCLUSION Readmission rates decreased 36.9% with implementation of the ICP. The IPC is an intervention that can be implemented easily across all settings and provides a strong foundation. This is true not only for HF but also for other chronic diseases such as diabetes and chronic obstructive pulmonary disease. The literature supports disease management discharge teaching, which incorporates warning signs of HF. Teaching patients how to treat their symptoms before they advance to severe exacerbations enables patients to remain independent for longer periods of time and manage their disease at home. The IPC also identified patients at risk and specifically those patients who needed a primary care provider in the area. In this rural community where primary care is limited, survival skills with symptom recognition ensure patients are able to manage their health more successfully. Discharge teaching using the “teach-back” methodology by staff nurses improved the quality of HF teaching prior to discharge. This with added support by inpatient teams providing nutrition consults and a plan of care for transitioning patients to home or a skilled nursing facility improved patient care postdischarge and contributed to preventing readmissions. Further home needs and concerns were addressed with a follow-up phone call, which provided our patients continuity of care outside the hospital system and, most importantly, enabled patients to address concerns that could be managed effectively. Patients without primary care were able to address concerns and needs after discharge to the care team, which, in turn, could provide assistance. Without the interdisciplinary team to provide multifaceted care and support on many levels, the patients would have not been as successful managing their symptoms once at home and preventing unnecessary hospital readmissions. REFERENCES 1. Heidenriech TJ, Khavjou O, Butler J, Dracup K, Ezekowitz O, Khavjou A. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-944. 2. Basoor A, Doshi N, Cotant J, et al. Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure. Congest Heart Fail. 2013;19(4):200206. 3. Centers for Medicare & Medicaid Services. Readmissions Reduction Program. http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html. Accessed July 1, 2014. 4. Simpson M. A quality improvement plan to reduce 30-day readmissions of heart failure patients. J Nurs Care Qual. 2014;29(3):280286. 5. Dewalt D, Schillinger D, Ruo D, et al. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation. 2012;125(2):2854-2862.
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6. Koelling T, Johnson M, Cody R, Aaronson K. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111:179-185. 7. Kommuri N, Johnson M, Koelling T. Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of randomized controlled trial. Patient Educ Couns. 2011;86(2):233-238. 8. Laramee A, Levinsky S, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population. Arch Intern Med. 2003;163:809-817. 9. Markley J, Andow V, Sabharwal K, Wang Z, Fennell E, Dusek R. A project to reengineer discharges reduces a 30-day readmission rates. Am J Nurs. 2013;113(7):55-64. 10. Naylor M, Brooten D, Campbell R, Maislin G, McCauley K, Schwartz S. Transitional care of older adults hospitalized with heart failure: a randomized control trial. J Am Geriatr Soc. 2004;52(2):675-684. 11. Rabbat J, Bashari D, Khillan R, et al. Implementation of heart failure readmission reduction program: a role for medical residents. J Community Hosp Intern Med Perspect. 2012;2(1):3-7. 12. Mulder B, Tzeng H, Vecchioni N. Preventing avoidable rehospitalizations by understanding characteristics of “frequent fliers.” J Nurs Care Qual. 2012;27(1):77-82. 13. DeWalt D, Callahan L, Hawk V, et al. Health literacy universal precautions toolkit. http://www.ahrq.gov/professionals/ quality-patient-safety/quality-resources/tools/literacy-toolkit/ healthliteracytoolkit.pdf. Published 2010. Accessed June 3, 2013. 14. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence. Crit Care Nurs. 2008;28(2):66-74.
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15. Schmeida M, Savrin R. Heart failure re-hospitalization of the Medicare FFS patient: a state level analysis exploring 30-day readmission factors. Prof Case Manage. 2012;17(4):155-161. 16. Takeda A, Taylor S, Taylor R, Khan F, Krum H, Underwood M. Clinical service organization for heart failure. Cochrane Collaboration. 2012;9:1-11. 17. Anderson C, Deepak BV, Amoateng-Adjepong Y, Zarich S. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congest Heart Fail. 2005;11(6):315-321. 18. Bradley E, Curry L, Horwitz L, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. AHA Circ Cardiovasc Qual Outcomes. 2013;6(3):444-450. 19. US Census Bureau. American fact finder: Farmville, Virginia. http:// factfinder.census.gov/faces/tableservices/jsf/pages/productview .xhtml?pid. Published 2013. Accessed January 29, 2015. 20. Onboard Informatics. Farmville, Virginia, city stats. http://www .city-data.com/city/Farmville-Virginia.html. Published 2013. Accessed January 28, 2015. 21. Anderson M, Levsen J, Dusio M, et al. Evidence based factors in readmission of patients with heart failure. J Nurs Care Qual. 2006;12(2):160-167. 22. Delisle D. Care transition programs: a review of hospital based programs targeted to reduce readmissions. Prof Case Manage. 2013;18(6):273-283. 23. Pollard J, Oliver-McNeil S, Patel S, Mason L, Baker H. Impact of the development of a regional collaborative to reduce 30day heart failure readmissions [published online ahead of print February 2, 2015]. J Nurs Care Qual. doi:10.1097/NCQ.000000 0000000116.
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Tailoring Your Heart Failure Project for Success in Rural Areas Martha Vesterlund, MSN, APRN, ANP-C; Bradi Granger, PhD, RN, FAAN; Terry J. Thompson, MD; Chuck Coggin III, MD; Marilyn H. Oermann, PhD, RN, ANEF, FAAN Purpose: The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model. Methods: An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge. Results: Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted. Implications: The IPC was effective in decreasing HF readmissions. Conclusions: These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF. Key words: heart failure readmissions, interdisciplinary plan of care, patient education, quality improvement,
readmissions
H
eart failure (HF) costs the nation $34.4 billion each year1 and is the most common Medicare diagnosis-related group for readmissions.2 The cost burden of HF and threat of no reimbursement from Medicare for HF readmissions have created the need to better manage care of these patients. In low-income and rural areas with lack of financial resources, the growing concern is loss of reimbursement, which might eventually lead to hospital closure and place the community at risk. The Centers for Medicare & Medicaid Services has initiated hospital quality measures, which include publicly reported 30-day readmission rates. Hospitals with high readmission rates can lose up to 3% of their Medicare reimbursement for 2015.3 Medicare payments traditionally were made to hospitals for each patient admission, regardless of the number and frequency of those admissions. With the institution of Author Affiliations: Medical Associates of Central Virginia, Appomattox (Ms Vesterlund); Duke University School of Nursing, Durham, North Carolina (Drs Granger and Oermann); Medical Director Hospitalist Service, Centra Southside Community Hospital, Farmville, Virginia (Dr Thompson); and Medical Associates of Central Virginia, Lynchburg (Dr Coggin). Correspondence: Martha Vesterlund, MSN, APRN, ANP-C, 2429 Purdum Mill Rd, Appomattox, VA 24522 ([email protected]; [email protected]). The authors acknowledge the following persons for their assistance: Julie Thompson, PhD, David Truitte, MD, Heather Bailey, BSN, RN, Dion Tomer, BSN, RN, Amanda Marsh, RN, Frieda Penzer, BSN, RN, Dennis Brown, LMSW, Brandy Earhart, MSN, RN, Kendall Wills Sterling, ELS. There are no disclosures, no conflicts of interest, no monies received for this work. Q Manage Health Care Vol. 24, No. 2, pp. 91–95 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
DOI: 10.1097/QMH.0000000000000055 April–June 2015 r Volume 24 r Number 2
readmission penalties, hospitals are now challenged to prevent readmissions to avoid these penalties.4 In areas without many resources outside the hospital, such as rural areas, it is essential for hospitals to address the problem of readmission for HF patients. Unplanned readmissions suggest issues with patient self-management and care transitions from hospital to home that reflect negatively on quality of care.4 Various studies have examined interventions incorporated into the patient’s hospital stay to prevent readmissions and improve quality of care. There are a growing number of studies on interventions for reducing readmission rates for the HF patient population. The majority of studies document the importance of disease management teaching compared with usual discharge teaching for the HF patient population.5-11 As part of this instruction, incorporating the “teach-back” strategy is pivotal in promoting patients’ understanding and avoiding rehospitalization.12 Teach-back is a way to confirm that nurses and other providers have explained to patients what they need to know in a manner that patients understand.13 Educating patients before discharge promotes self-care, decreases readmissions, and helps patients identify problems early once at home.14 Other interventions for improving quality of care for patients with HF and preventing readmissions include a follow-up phone call and appointment within 5 to 7 days with their primary care provider.6,8,10,15,16 Other studies have examined the effects of incorporating multiple interventions into a plan of care for these patients. These studies found improvements in readmission rates from 3% to 18%, with 1 or 2 interventions5–7,10 to 6 total interventions provided for HF patients.8,9,17,18 For example, Bradley et al18 studied the effects of www.qmhcjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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integrating 6 interventions into the plan of care for patients with HF, which, in turn, improved readmission rates. LOCAL PROBLEM Our nonprofit hospital’s readmission rate for HF patients ranged from 20% to 25% for the years 20092013, above the national average. Patients received general discharge teaching and case management, but there were no strategies in place to ensure follow-up care for these patients. PURPOSE
The purpose of this quality improvement project was to decrease 30-day readmission rates for patients with HF through the development and implementation of a new integrated plan of care (IPC) for these patients. The IPC included 6 interventions: (1) detailed HF education for patients and families; (2) a discharge HF packet; (3) nutrition education; (4) case management; (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge; and (6) a follow-up phone call to each patient within 48 hours postdischarge. The interventions included in the ICP are particularly important for patients in a rural community who may have limited access to resources and education. METHODS Design
The HF project design was a quality improvement study on the effects of an IPC on HF readmissions. All patients admitted under the 291-293 diagnoses codes for HF starting July 15, 2014, to October 31, 2014, received the new IPC and were followed using prospective chart review. Setting
Southside Community Hospital is a not-for-profit, 86bed facility that serves a rural community in Virginia. The unemployment rate for this community is 9.8%, which is above the state average of 5.4%.19 The median household income is significantly below state average ($24 582 vs $61 741).20 Outside sources including primary care physicians are lacking in this area, which, in turn, cause patients to use the emergency department for their primary care. Sample
Inpatient HF patients older than 18 years with a primary diagnosis of acute HF (diastolic or systolic, preserved left ventricular ejection fraction) admitted for acute care at the Southside Community Hospital were included in the project. A total of 61 patients admitted with the diagnosis of HF received the IPC. Patients could speak and understand English. The readmission rates for patients with HF admitted a year prior to and the quarter before implementing the new
www.qmhcjournal.com
plan of care were used as the baseline measure. The project was approved by the university and hospital institutional review boards. Informed consent was not required. Intervention
To better prepare patients for managing their HF at home and to reduce readmission rates, an IPC was developed and implemented for these patients. The IPC included the American Heart Association “Get With the Guidelines” tool kit and a teach-back tool used to implement quality discharge teaching by staff nurses. Nurses provided detailed HF education including medication instructions and care at home including teaching them home survival skills such as symptom recognition (increased dyspnea, weight gain, and edema) and proper treatment of these symptoms. Patients received a discharge packet that included an HF calendar for documentation of their daily weights and the symptom evaluation brochure. These educational materials were available but not used at our hospital until initiation of this project. The packet also included a list of patients’ follow-up appointments and provider telephone contact numbers and dietary limitations. As part of the IPC, patients were referred to the nutrition team and received education about dietary restrictions and a low-sodium and low-fat diet. Patients also were referred to case management. The case manager initiated home health services and skilled nursing facility placement as needed and established a primary care provider for those HF patients without one prior to discharge. The IPC included follow-up appointments with patients’ primary care provider for 5 to 7 days postdischarge and with their cardiologist for 2 weeks after their discharge. These appointments were made for patients during their hospital stay. The telephone numbers for patients’ providers were listed in their discharge packet. Finally, patients received a follow-up phone call from the charge nurse, staff nurse, or nurse practitioner within 48 hours to answer patients’ questions and confirm their follow-up appointments. This follow-up call incorporated the teach-back tool to review patients’ understanding of symptoms and evaluation of further needs. To prepare nurses for teaching patients, a PowerPoint presentation was developed for the nurses to complete at the start of the project. This presentation included a review of HF, education on HF medications, an explanation of teach-back strategies to help nurses evaluate how well patients comprehended their disease management teaching, and other essential areas of teaching about HF. The nurses completed a 15-item preand posttest. The mean percent correct increased from 53% at pretest to 96% at posttest, indicating nurses had learned this content, which is essential for teaching patients and families prior to discharge. Procedures
An administrative data sheet was printed for the medical-surgical unit each day with all HF patients
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
April–June 2015 r Volume 24 r Number 2
admitted during the previous 24 hours; the nurse practitioner or charge nurse rechecked all admissions for the hospital to identify other patients with HF not included on this data sheet. A “call-back” questionnaire was added to the patient’s charts with an identifying sticker that the patient had HF. There was a checkoff box by nursing staff in the hospital Electronic Medical Record (EMR) to verify that HF discharge teaching was completed. Under the same Portal database, case management and nutrition services also checked off their involvement in the patient’s care. A weekly chart review was used to verify that all components of the ICP were implemented and that each component was documented in the EMR. When patients were discharged, whether they received an HF packet at discharge and confirmation that their follow-up appointments were made were written on the call-back questionnaire. Review of the administrative data sheet compared with the patient census revealed patients who were discharged without an HF packet and follow-up appointments made for them. The data were then deidentified by the quality improvement team, and checkoffs were categorized into an Excel spreadsheet. Data were available in the EMR to verify whether the patient was readmitted within 30 days. Data analysis
Patient demographic data were analyzed using descriptive statistics. The readmission rate that was reported prior to the IPC was calculated according to administrative data. Readmission rate was calculated as the number of patients readmitted with HF out of the total number of patients admitted with HF and then multiplied by 100 to get a percentage. The percent change was calculated using the following formula:
( p1 − p2 ) × 100 p2
Fidelity in completing the 6 interventions was conducted for each admission and readmission and was analyzed using cross tabs and the χ 2 test. Relative risk ratio for HF teaching was conducted, and the risk estimate was calculated with a 95% confidence interval. Data were analyzed using IBM SPSS Statistics for Windows, version 22.0. RESULTS Under the diagnostic codes 291, 292, and 293, all patients (n = 61) were eligible for this program and all patients participated. Of the 61 patients, 31 were men, and the mean age was 75.9 years. There were 34 patients with Medicare, 3 with Medicaid, 20 self-pay, and 4 with private insurance. Thirty black, 30 white, and 1 Asian patient participated in the study. Thirty-day readmission rate
The 30-day readmission rate for patients with HF in 2013, prior to the project, was 20.9%. Over a 3-month
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period, 61 patients with HF participated in the project and received the ICP. Of those 61 patients, only 8 (4 women, 4 men) were readmitted within 30 days, a readmission rate of 13.2%. The percent decrease in readmissions was 37.3%, calculated using the following formula: ( p1 − p2 ) p2 × 100. The 13.2% readmission rate was also compared with the hospital’s quarterly readmission rate during the project time period, which was almost the same at 13.1%. In addition to comparing our HF readmissions with the hospital’s 2013 rate, the quarterly results just prior to the beginning of the project were examined; the 2013 rate was consistent with the quarterly results according to administrative data. Of the 6 interventions in the ICP, each patient received all of the interventions except for 17 people who did not have a nutrition consult and 4 who did not receive the HF discharge teaching. None of the interventions were significantly associated with readmission except for HF discharge teaching, which significantly impacted readmission rates. Of the 61 patients, 8 were readmitted. Of these 8 readmissions, 4 patients had not received HF teaching with the updated discharge packets. Those patients who did not receive the teaching were almost 7 times more likely to be readmitted (n = 4 of 8 patients; 50%) than those who received the teaching (n = 4 of 53 patients; 7.5%; P = .007). Of the 8 readmissions, 4 patients had Medicare and 3 were self-pay, and 6 of the 8 readmitted patients were older than 80 years.
DISCUSSION With readmission penalties imposed by the Centers for Medicare & Medicaid Services, all hospitals run the risk of losing much needed reimbursement. Loss of financial compensation threatens hospital closure, which, in turn, would decrease access to health care for the community. In rural areas where care is limited, the risk of losing hospital facilities is worrisome. Having a plan of action at home with instructions on how to manage symptoms, and when to call the primary care provider or cardiologist, helped patients from being readmitted. Literature on preventing readmissions supports follow-up phone calls after hospital discharge.4,5,10,17,18 In this project, patients were telephoned within 48 hours of discharge, educational support was provided, and home services (such as home health) were initiated postdischarge if needed. During this phone call, patients who were unable to fill their prescriptions at discharge, who needed home health services but declined it during hospitalization, and who were using the educational materials provided at discharge were identified. Incorporating home health services for patients with chronic disease has also been supported in other studies.18,21,22 In addition, home health nurses evaluated symptoms for patients at follow-up and at times instructed decompensating
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patients to follow up with their primary care providers or cardiologist sooner. The IPC improved care for these inpatients in this rural community. Improvements in clinical outcomes with using HF multifaceted discharge teaching were effective in preventing readmissions. When compared with patients with HF disease–specific teaching by nursing staff at discharge, the patients who did not receive this education were 7 times more likely to be readmitted. The strategies for HF patients and multidisciplinary team involvement used in this project to prevent readmissions are supported by other studies.17,18,22 Multidisciplinary disease management programs can substantially reduce readmissions for HF.17 In this project, multiple disciplines working together transitioned patients to proper home health services, which, in turn, prevented readmissions. Home health nursing staff further reviewed and supported the interdisciplinary team after discharge using the HF education packet with patients at home to stress the importance of symptom recognition and treatment. Treating their symptoms before they advanced to severe exacerbations enabled patients to remain independent for longer periods of time and manage their disease at home. In geographical areas with limited health care resources, hospitals are under increasing pressure to address the problem of readmission for patients with HF. In low-income areas with a lack of financial resources, the growing concern is loss of reimbursement, which might lead to hospital closure. In areas without many resources outside the hospital, it is essential to have hospital facilities to care for this population. This project’s goal was to encourage self-care at home to prevent HF readmissions in this rural community where sources are scarce outside the hospital system. By using an IPC and incorporating the support of a variety of specialties on the nursing care team, combined with interdisciplinary team involvement, readmission rates fell dramatically. Integrating multifaceted interventions into an IPC specific for a rural, low socioeconomic community demonstrated a commitment by the entire health care team to improve quality of care. In addition, our connection with outpatient services strengthened during this project and the interdisciplinary team established vibrant relationships with patients.23 Limitations
This is not representative of all rural community hospitals throughout the United States. The actual home practices of the patients cannot be determined from this project. Patients’ compliance with medications and diet is a common cause of HF exacerbations that can directly affect readmission. Nurse navigators are not employed by this specific hospital, thus following patients to evaluate compliance with follow-up appointments and medication was not possible. The readmission rates reported could be an underestimation, as HF readmissions outside our health care system could not be accounted for. Further research into disease man-
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agement teaching at discharge and patient noncompliance issues is warranted to fully understand caring for vulnerable populations. CONCLUSION Readmission rates decreased 36.9% with implementation of the ICP. The IPC is an intervention that can be implemented easily across all settings and provides a strong foundation. This is true not only for HF but also for other chronic diseases such as diabetes and chronic obstructive pulmonary disease. The literature supports disease management discharge teaching, which incorporates warning signs of HF. Teaching patients how to treat their symptoms before they advance to severe exacerbations enables patients to remain independent for longer periods of time and manage their disease at home. The IPC also identified patients at risk and specifically those patients who needed a primary care provider in the area. In this rural community where primary care is limited, survival skills with symptom recognition ensure patients are able to manage their health more successfully. Discharge teaching using the “teach-back” methodology by staff nurses improved the quality of HF teaching prior to discharge. This with added support by inpatient teams providing nutrition consults and a plan of care for transitioning patients to home or a skilled nursing facility improved patient care postdischarge and contributed to preventing readmissions. Further home needs and concerns were addressed with a follow-up phone call, which provided our patients continuity of care outside the hospital system and, most importantly, enabled patients to address concerns that could be managed effectively. Patients without primary care were able to address concerns and needs after discharge to the care team, which, in turn, could provide assistance. Without the interdisciplinary team to provide multifaceted care and support on many levels, the patients would have not been as successful managing their symptoms once at home and preventing unnecessary hospital readmissions. REFERENCES 1. Heidenriech TJ, Khavjou O, Butler J, Dracup K, Ezekowitz O, Khavjou A. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-944. 2. Basoor A, Doshi N, Cotant J, et al. Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure. Congest Heart Fail. 2013;19(4):200206. 3. Centers for Medicare & Medicaid Services. Readmissions Reduction Program. http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html. Accessed July 1, 2014. 4. Simpson M. A quality improvement plan to reduce 30-day readmissions of heart failure patients. J Nurs Care Qual. 2014;29(3):280286. 5. Dewalt D, Schillinger D, Ruo D, et al. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation. 2012;125(2):2854-2862.
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6. Koelling T, Johnson M, Cody R, Aaronson K. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111:179-185. 7. Kommuri N, Johnson M, Koelling T. Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of randomized controlled trial. Patient Educ Couns. 2011;86(2):233-238. 8. Laramee A, Levinsky S, Sargent J, Ross R, Callas P. Case management in a heterogeneous congestive heart failure population. Arch Intern Med. 2003;163:809-817. 9. Markley J, Andow V, Sabharwal K, Wang Z, Fennell E, Dusek R. A project to reengineer discharges reduces a 30-day readmission rates. Am J Nurs. 2013;113(7):55-64. 10. Naylor M, Brooten D, Campbell R, Maislin G, McCauley K, Schwartz S. Transitional care of older adults hospitalized with heart failure: a randomized control trial. J Am Geriatr Soc. 2004;52(2):675-684. 11. Rabbat J, Bashari D, Khillan R, et al. Implementation of heart failure readmission reduction program: a role for medical residents. J Community Hosp Intern Med Perspect. 2012;2(1):3-7. 12. Mulder B, Tzeng H, Vecchioni N. Preventing avoidable rehospitalizations by understanding characteristics of “frequent fliers.” J Nurs Care Qual. 2012;27(1):77-82. 13. DeWalt D, Callahan L, Hawk V, et al. Health literacy universal precautions toolkit. http://www.ahrq.gov/professionals/ quality-patient-safety/quality-resources/tools/literacy-toolkit/ healthliteracytoolkit.pdf. Published 2010. Accessed June 3, 2013. 14. Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence. Crit Care Nurs. 2008;28(2):66-74.
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