Reducing Heart Failure Hospital Readmission Rates among the Elderly: Lessons Learned from One Community Hospital

Thursday, 15 July 2010

Yvonne KitYing Chan, RN, MSN, GCNS-BC, PHN
Department of Nursing, Chinese Hospital, San Francisco, CA

Learning Objective 1: recognize common contributing factors for hospital readmissions among heart failure patients.

Learning Objective 2: describe three patient educational strategies for geriatric patient self-monitoring and identification of worsening heart failure symptoms.

Funded by the Betty & Gordon Moore Foundation and supported through Chinese Hospital Association (CHA) in-kind contributions, the collaborative project is part of the Institute for Healthcare Improvement (IHI) Transforming Care at the Bedside (TCAB) program, the Transitions Home component that focuses on optimizing discharge planning for heart failure patients over 65 years old for up to three months. The objective of the program is to decrease the number of readmissions by 30% over two years and to facilitate the transition from the hospital to the next appropriate setting. We focused on changes by a) identifying discharge needs beginning on the day of admission, b) implementing focused teaching of patients and caregivers, c) communicating pertinent patient and family information to the next appropriate setting, and d) initiating post-discharge follow-ups within three to five days with medical providers. Implementation strategies include learning from evidence-based and other hospitals’ best practices, collaborating with other disciplines and hospitals, and updating existing protocols and policies. Education strategies were customized for our predominant geriatric Chinese population to enhance monitoring and management of their chronic illnesses. Our educational materials included the use of pictures with written in easy-to-understand language in large fonts. Discussion on patient status is updated with home care services periodically. The biggest impacts on our project occur after discharge with the use of follow-up home visits and/or telephone calls to reinforce discharge instructions & MD follow-ups, the assessment of patients’ home situations, and monitoring their educational/care needs and barriers. We have learned that patient can be empowered to report abnormal signs and symptoms in a timely manner and avoid emergency visits and hospitalizations.