Heart failure program cuts readmission rate
Nurses call patients 18 times in a month
After Southeast Alabama Medical Center in Dothan began a heart failure readmission prevention program, its 30-day readmission rate dropped to an average of 13%. In January, the hospital discharged 62 heart failure patients and only 8% were readmitted.
A key component of the heart failure program is the post-discharge follow-up program, in which a dedicated RN in the medical call center calls patients a total of 18 times each in the weeks after discharge to check on them and support them in following their treatment plan.
"Making 18 calls to each patient may sound like a lot, but the calls drive the message home. The more you call, the more the information is going to stick. The average cost for heart failure readmissions is $9,000. If multiple calls will keep patients from being readmitted, it just makes sense to do it," says Kevin Ross, RNC, clinical coordinator and call center manager for the 420-bed facility.
Here’s how the program works, according to Ross:
The case managers on the floor send the call center information on all the heart patients in the hospital. The call center staff access the discharge summary and the medication list in the hospital’s electronic medical record and enter it into the call center’s customized software program. The program automatically brings the names of the patients slated for calls into the work queue each day. The call center nurse uses a built-in script that is based on the hospital’s heart failure educational program and makes notes on patients’ concerns and problems that need follow up.
The nurse makes the first call to the patient within 72 hours of discharge and spends 30 to 45 minutes making sure the patients have everything they need and that they understand their condition and their treatment plan. Other calls are usually shorter, depending on the patient’s questions and concerns. At the end of each call, the nurse coordinates the best time for the next call.
The nurse follows up with patients every day for the next nine days, then every other day for another 10 days, and then every third day for another ten days.
About 20% of the heart failure patients opt out of the follow-up calls, Ross says. "These are the younger patients who want to be independent and feel like they don’t need reminders about their treatment plan. The older patients say it gives them a sense of security to know that somebody will be calling to check on them," Ross says.
The main purpose of the calls is to reinforce the education that patients received in the hospital, help them understand their goals, and support them in following their treatment plan, according to Ross. The nurse makes sure patients have their medication and understand how to take it, then checks back on following calls to make sure the patients are taking medication properly.
"Medication is the number-one issue. We have found that many patients continue to take the medications they were taking before admission as well as the discharge medication. The calls have really made a difference in helping patients understand their medication regimen," says Melanie McKnight, division director of registration service. The hospital has begun an in-house pharmacy program that enables patients to get their prescriptions filled before they leave.
The nurse ensures that patients have a follow-up appointment with a physician and can help them get an appointment if needed. The nurse makes sure the patients have scales, that they understand their dietary restrictions, and answers questions. If needed, the nurse can contact the nurse or case manager who cared for the patient in the hospital for help in securing medication assistance or providing scales.
The initiative grew out of a year-long journey aimed at reducing length of stay, says Lara McCall, RN, BSN, director of case management. "We were working on reducing length of stay, but we knew that with the shorter stays, we had to take steps to make sure the patients didn’t come back," she says.
The Centers for Medicare & Medicaid Services’ readmission reduction program made it imperative that the hospital focus on cutting admissions, Ross adds.
The hospital created a multidisciplinary heart failure team to look at ways to reduce heart failure readmissions. The team based the hospital’s plan on what other providers were doing as well as research by a nurse who was working on her master’s degree, Ross says.
The multidisciplinary heart failure team included case managers, direct care nursing staff, the emergency department case manager, emergency department nurses, a data analyst, a clinical educator, two nursing directors, a hospitalist who is the physician champion, call center staff, and a nutritionist.
The medical call center already had a nurse line operating 24 hours a day for medical triage calls. "It was logical for the call center RNs to make the follow-up calls, but we couldn’t do it with the staff we had. We conducted a pilot project with existing staff to see if we could make a difference," McKnight says.
The pilot was a success, and the call center was able to hire a nurse to call all heart failure patients during business hours.
The call center team was changing software vendors at the time and had candidates include the follow-up phone calls in their proposals.
"We had the software modified to meet our needs. The call scripts, documentation, and tracking are all built in to guide the staff when they call patients. This format has helped us keep track of who gets called every day, give a consistent message to our patients, and analyze data to determine where we can make improvements," McKnight says.
The call center team meets with nursing and case management every two weeks to discuss what the data show.
"Through the information gleaned from the calls, we determined that despite our best efforts to educate patients on heart failure and their treatment plan, they were retaining only about 10% of the information. When people are sick, it’s not the best time to educate them. The follow-up calls make a world of difference. The patients are feeling better and the education makes more sense to them," McCall says.
The hospital’s nursing director and nursing educator developed a heart failure booklet, written on a sixth-grade level.
Now the patient care nurse goes over the discharge teaching when the patients are in the hospital and gives them a heart failure booklet that was written by the hospital’s nursing directors and nursing educator, according to McCall.
The hospital also mails patients a packet of information that explains the follow-up phone calls and their purpose and includes the discharge education and the heart failure booklet, along with information on their diet, the importance of weighing themselves, and a repeat of other discharge education, according to Ross.
The hospital provided the same educational materials to the home health providers in the area. "Now patients receive the same information in the hospital, during the follow-up calls, and from the home health nurses," McCall says.
As part of the initiatives, the case managers review the cases of all patients who are readmitted, find out the reason they were readmitted, and report to the readmission team.
"Some patients are just non-compliant, but others lack access to care. We have a big shortage of primary care providers in our area, and we are looking at ways for patients to get the follow-up care they need. The information the case managers provide helps us identify patterns and take steps to improve our program," McCall says.
