Hospital Readmissions in patients diagnosed with CHF By Robyn Ashinhurst, LPN Melissa Teets, LPN Randi Elrod, RN Heart Failure (HF) Admission •Leading cause of hospitalization adults >65 •Over 1 million hospitalized per year •Total Medicare Expenditure: $17 billion/ year (Bradley, 2012) Hospital Readmission Rate (HRR) With current standards of care… •Up to 50% within 30 days of discharge • Up to 75% are preventable •30% within 60-90 days •>50% within 6 months (Bradley, 2012) PICO Question How does outpatient care coordination compare to standard inpatient discharge planning in the reduction of hospital readmission of adult patients with congestive heart failure? Standard Inpatient Discharge Planning •Dietary Recommendations •Daily weight monitoring •Medication education • Usually only newly prescribed •When to contact primary care physician •Referral to primary care physician Outpatient Care Coordination •Home Health Visits •Telemonitoring •Outpatient Clinic Visits •Primary Care Physician Visits Review of the Literature Kent, et al. (2011) systematic review Education-focused interventions had greatest effect on… • Daily Weight Monitoring Compliance • Reporting Weight Gain to PCP Two studies: minimal effect on medication compliance Self-care behaviors decreased after 1 month Likely due to… • Lack of education reinforcement • Memory problems associated with aging Review of the Literature Syler, et al. (2011) systematic review Interventions: • Intense in-hospital education • 3+ dietician consults • Optimum HF medication regimen • Telephone & HF clinic follow-up Results: • 0 HRR at 30 days, compared to 50% • 2% HRR at 3 months, compared to 30% Review of the Literature Benbassat & Taragin (2013) meta-review • Over 63,000 patients • 57 meta-analyses & 47 systematic reviews • 40 combinations of interventions Total HRR of 4.2% • Follow-up Visits + Education = 3.7% HRR in 12 months • Clinic + Calls = 3.7% HRR in 6-12 months • Home Visits + Calls + Clinic= 3.2% HRR in 12 months Protocol Recommendations Improved Inpatient Discharge Planning + Outpatient Care Coordination • Effective Individualized Patient Education • Telemonitoring • Home Health Visits • Clinic Follow-Up & Monitoring • Excellent Communication Between Health Care Providers Effective Patient Education INDIVIDUALIZED self-care plan with… • Heart Healthy Diet & Lifestyle Changes • Exercise, smoking, alcohol • Weight Monitoring & Training • Provide scale if needed • Recognize Condition Changes & When to Notify • Edema, dyspnea, increased # of pillow usage Effective Patient Education • Medication Management/Education • Provide weekly med dispenser if needed • A Written Manual with Verbal Explanations • Additional 1:1 sessions to reinforce education • Family & caregivers included in teaching • Periodic Education Evaluation Surveys • Patient’s/caregiver knowledge of disease/care Telemonitoring • Nurse call within 72 hours for baseline • Weekly calls for 6 weeks, then monthly • Additional scheduled calls as needed • 24/7 nurse contact number Home Health Visits • Nurse visit within 1 week • Weekly visits for 4 weeks, then monthly • Additional visits as required • Cardiovascular exams/symptom assessments • Self-care behavior compliance monitoring • Assess knowledge & education reinforcement Clinic Follow-up & Monitoring • Primary care visit within 2 weeks • Cardiologist clinic • At week 1 & at months 1, 2, 3,6, 9, & 12 • Medication review every visit • Dietitian consultations initially & as needed Evaluation Methods for Recommended Protocol Monitor Readmission Rates & Intervals Identify Number/Nature of Exacerbations At different Intervals throughout care: • Survey knowledge of disease process • Survey self-care behaviors Suggestions for Further Study Further Studies Should: • Be conducted on younger populations (< 65 years) • Be conducted for longer periods of time (> 12 months) • Be restricted to trials that test specific interventions in similar populations for comparison • Ensure interventions aimed at reducing readmissions do not compromise patients’ health by reducing justified readmissions References Benbassat, Jochanan, and Taragin, Mark. (2013). The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses. Israel Journal of Health Policy Research. Retrieved from: http://www.ijhpr.org/content/2/1/1. Bradley, Elizabeth H., et al. (2013). Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circulation: Cardiovascular Quality and Outcomes. American Heart Association. Retrieved from: http://circoutcomes.ahajournals.org. Casmir, Yves E., et al. (2014). The effectiveness of patient-centered self-care education for adults with heart failure on knowledge, self-care behaviors, quality of life, and readmissions: a systematic review. JBI Database of Systematic Reviews & Implementation Reports. doi:10.11124/jbisrir-2014-1438. Kent, Bridie, Cull, Emily, Phillips, Nicole, M. (2011). A systematic review of the effectiveness of current interventions to assist adults with heart failure to comply with therapy and enhance self-care behaviours. JBI Library of Systematic Reviews. 9(59)2572-2626. Kommuri, et al. (2012). Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial. Patient Education and Counseling. 86 233238. Syler, Jason T., et al. (2011). A systematic review of the effectiveness of nurse coordinated transitioning of care on readmission rates for patients with heart failure. JBI Library of Systematic Reviews. 9(15):464-490.
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