The Patient Navigator Program to Reduce AMI and HF Readmissions

Background: Hospital readmissions across the country are high, and heart failure patients make up a majority of those readmitted. The heart failure and myocardial infarction readmission rate for Medicare patients averaged 24.4% and 19.5% nationally. Nearly 1 in 5 patients hospitalized with heart attack and 1 in 4 patients hospitalized with heart failure is readmitted within 30 days of discharge.

Purpose: A Patient Navigator Program seeks to reduce avoidable hospital readmissions by making hospitalizations less stressful and the recovery period more supportive by implementing evidence-based quality improvement strategies. 

Description: The Patient Navigator Program was developed in response to data that suggest readmissions can be prevented by: improving early follow-up, medication management and empowering patients to take an active part in their recovery. The support of a well-trained “navigator” team can be effective in improving patients’ transitions from hospital to home. In our hospital, we have developed and applied patient-centered solutions that address functional disabilities, stressors, and other challenges confronting heart attack and heart failure patients—both during their hospital stay and post-discharge—that increases these patients’ risk of readmission. Our multidisciplinary team consists of Physicians, Nurses, Pharmacists, Nutritionists, Case Managers, Social Worker, Physical Therapist, and Administrators who liaise with patients through the physiological, psychological, and logistical challenges. A LACE risk stratification score is used to target bundled interventions such as Pharmacist and Nutritionist 1:1 teaching, Case Managers who order Home Health services and Community Care Transitions Program (CCTP), and a specialized team who schedules follow-up appointment(s) prior to discharge.  Our hospital is part of a cohort of 14 other hospitals that is working to set standards for reducing readmissions and serve as a national infrastructure for transitions of care.

Conclusion: There are numerous factors that cause hospital readmissions. By implementing evidence-based quality improvement strategies with a multidisciplinary team based approach, we hope to reduce readmissions in the AMI and HF patient population and serve as a national infrastructure for transitions of care.