Discharge Program Using a Coaching Model to Reduce Readmissions Rate in Heart Failure

Swartz, M. Jane

Saturday, 29 October 2011

M. Jane Swartz, APRN, MSN
Nursing and Health Professions, University of Southern Indiana, Evansville, IN

Learning Objective 1: 1)discuss the impact of readmission rate on patients and their families and the healthcare system.

Learning Objective 2: 2)identify the key components of the coaching program for patients discharged with heart failure

Heart failure is chronic progressive disease with a complex management regime. Following the patient’s stabilization in the acute care facility, a vulnerable period in the continuity of care exists in the transition from acute care setting to the home environment. Heart failure is associated with a high rate of potentially preventable readmissions within thirty days of discharge from the acute care setting.

In a data analysis from 2005 Medicare discharge claims, the rate of potentially preventable readmissions related to heart failure was found to be 12.5% within the first 15 days following discharge from the initial in-patient stay. The average Medicare payment for each readmission is $6,531.00 with a total spending on readmissions for heart failure at $590,000,000 (MedPac, 2007). Jencks, Williams, and Coleman (2009) reviewed data from 2003-2004 finding the readmission rate to be 19.6% for Medicare beneficiaries within 30 days of discharge. Of the readmissions, 90% appear to be unplanned. Jweinat (2010) writes that the cost to Medicare for unplanned readmissions in 2004 was $17.4 billion out of a total hospital payment of $102.6 billion.

The Health Care Excel which serves as the Indiana Medicare Quality Improvement Organization finds the readmission rate for the Evansville service area at 20-22%. Thus a community effort of institutions was formed to improve cooperation and communication with a common goal to reduce the rate of readmissions by 2%.

At The Heart Hospital at Deaconess Gateway the discharge process will be adapted using The Transitional Model by Eric Coleman. The key component to reducing readmission after hospitalization is the patient’s ability to actively participate in their disease management. A “coach” meets with patient prior to discharge and then weekly via home visit or telephone. The coach uses strategies to improve patient and families understanding of self-management.

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