Cheri Basso BSN, RN-BC,CHFN Hospital Initiatives to Improve Outcomes. FINANCIAL DISCLOSURE: No relevant financial relationship exists

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1 Cheri Basso BSN, RN-BC, CHFN Mary Washington Healthcare Fredericksburg, VA Cheri Basso BSN, RN-BC,CHFN Hospital Initiatives to Improve Outcomes FINANCIAL DISCLOSURE: No relevant financial relationship exists

2 Transition Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:.

3 Make accessible Summarize key points Staff education Tracer Methodology Trace patient through continuum Evaluate actual care against guidelines GAP Analysis Look for gaps in care Gaps become opportunities for Applied Tracer Methodology: improvement Tips and Strategies for Continuous Systems Improvement.

4 Adapted from Yancy CW, Jessup M, Bozkurt B, et al ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:.

5 CHART REMINDERS & DISCHARGE ORDERS GET WITH THE GUIDELINES PATIENT MANAGEMENT TOOL Get with the Guidelines. American Heart Association. 1.Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, Moser DK, Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010;16: Target HF. American Heart Association. Accessed October 3, 2013.

6 Advanced age Multiple co-morbidities Multiple specialists Dementia or cognitive dysfunction Financial challenges Lack of social support Poor functional capacity and fatigue Depression Cultural barriers Focus on key elements Address low health literacy issues Ongoing education Teach back Consistency across continuum Source: Nielsen GA, Bartley A, Coleman E et al. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure. Cambridge, MA: Institute for Healthcare Improvement; Available at

7 Order sets drive multidisciplinary consults Consolidating patients on HF Unit Staff are experts Processes hard-wired Excerpt from HF Orderset Full-time RN position Automatic consult Primary goals Patient education Identify barriers Care coordination Readmission interview Expanded to other diagnoses HF Navigator Note

8 Dietary Consult Defined education 7-day menu plan 30 day Plan

9 Yancy C, Albert N. Target: Heart Failure - An Extended Hour with our Experts. American Heart Association Webinar Outline next steps for patient/caregiver Reason for hospitalization Comprehensive list of medications Warning signs and actions to take Follow-up diagnostics and/or pending results Contact information for questions that arise Follow-up appointment Several models Project RED After Hospital Care Plan Project BOOST Patient PASS: A transition record Care Transitions Intervention Personal Health Record

10 Reviewed 11,855,702 Medicare beneficiaries claims 50.2% of patients readmitted within 30 days of a medical discharge had no claim for a physician s office visit between discharge and rehospitalization. Early outpatient follow-up varies significantly across US hospitals Median follow-up visit within 7 days = 37.5% Among hospitals with higher rates of early follow-up, risk for readmission is lower; 15% reduction Best Practice Recommendations Days to Follow-up 2013 ACCF/AHA HF Guidelines 7 14 days The Joint Commission - ACHF American Heart Association - Target HF American Heart Association GWTG Achievement Award Quality Plus Award 7 days 7 days No timeframe 7 days

11 HF-focused visit as 1 st visit Cardiologist or HF Clinic Collaborate with community physicians Spacing of appointments Individualized to patient s needs Develop hospital process to address when, who and how the appointments will get made Begins at admission Navigator & unit secretary Cardiologists Discharge nurse Back-up process

12 Arrange for post-discharge evaluation within 72 hours Phone call Home health nurse visit Transition coach visit Clinic visit

13 Recommended Components of a Post-discharge Evaluation Assessment of health status Medicine check Clarification of clinician appointments and lab tests Coordination of post-discharge home services Review what to do if a health or medical problem arises Jack B. Project RED: Re-engineered discharge. Nurse call center First call in hrs Six calls over 30 days Nurse access to EMR Calls scripted based on protocol

14 Results of the Study Direct communication between hospital physician and PCP Availability of a DC Summary at 1 st post-discharge visit Availability of a DC Summary at 4 weeks 3-20% 12-34% 51-77% Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospitalbased and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8): Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospitalbased and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-41

15 Analyze, analyze, analyze Understand your data Base PI on the data Re-evaluate often and adjust plan accordingly Retrospective chart reviews Concurrent chart reviews Review of index admission for opportunities Patient interview Actively addressing any identified needs Identify themes each month Medical management Process Patient non-adherence Advanced HF Coding

16 Cheri Basso BSN, RN-BC, CHFN Heart Failure Program Coordinator Mary Washington Healthcare

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