Stopping the Revolving Door of CHF Readmissions




Cheryl Anderson, RN, Senior Consulting Director

The statistics are scary. Nearly 5 million Americans are currently living with congestive heart failure (CHF) and approximately 550,000 new cases are diagnosed in the U.S. each year. But, that’s only part of the story. Along with diabetes mellitus, chronic obstructive pulmonary disease and acute myocardial infarction, CHF patients fall into the all too familiar group of diseases significantly contributing to preventable hospital readmissions. Scary, too is the financial and reputational impact high readmission rates can have on a health care organization.

Of the major chronic illnesses noted above, patients with CHF can be the most costly to acute care hospitals. The most common reasons include inconsistent monitoring of an outpatient’s dose titration, a patient’s lack of compliance to a treatment plan or the absence of follow-up care after discharge. Moreover, CHF patients usually experience major physical challenges that manifest themselves through fluid retention, shortness of breath and fatigue. Consequently, patients with CHF have a higher risk of mortality within five years of diagnosis. Clearly, it’s critical for these patients to have closely monitored care to manage their disease and have quality of life. 

Many health systems are intensifying their efforts to address CHF comorbidities and reduce preventable readmissions through discharge planning programs that incorporate transitional care and multidisciplinary teams. But, what do these programs look like and how can your organization get started?

Discharge plan in review

The first step to improvement is conducting a thorough assessment of your current processes. I recommend developing a risk assessment tool for identifying those patients who are at a high risk of being readmitted within 30 days of discharge with the diagnosis of CHF. By identifying these CHF patients within 48 hours of their admission, the nurse manager can begin the discharge planning process. When evaluating your current discharge plan, the benefits of including transitional care elements to ensure that the needed care and services are provided from the hospital to the home setting cannot be overstated.

A great case study of success comes from Kaiser Permanente Northwest. Researchers evaluated their patient-centered transitional care bundles that included CHF discharge medication reconciliation, scheduling of the first post-discharge appointment with the primary care physician, standardized patient discharge instructions, and assessing the home care needs of the discharged CHF patient. They found that implementation of a patient-centered transitional care bundle decreased CHF readmissions from 12.1 percent to 10.6 percent and improved patient care satisfaction.

The right team

When assessing and considering changes to your discharge process, the most creative and innovative organizations take steps to utilize one of their best and viable resources: their nurses. Research shows that organizations with discharge planning programs that encompass nurse-managed multidisciplinary teams along with the transitional care components can reduce CHF readmission rates by two days and reduce all-cause mortality by 30 percent.

In addition to nursing, other professional caregivers critical to the success of the CHF discharge planning process include pharmacists, nutritionists, nursing educators, physical therapists, physicians and case managers.

In another study, a hospital implemented a re-engineered discharge (RED) program to decrease CHF readmission rates. These participating RED study hospitals implemented multicomponent discharge planning processes involving medication reconciliation, disease management educational programs, scheduling the patient’s first appointment after discharge, and home care needs assessment. Consequently, the hospitals that implemented the RED program experienced a 2 percent reduction in CHF readmission rates compared to those hospitals not participating in the RED study. 

Hospitals that have included the steps noted above have made great progress in lowering their readmission rates. It requires a combination of assessing the problem, developing a discharge plan that incorporates the right team with the appropriate elements, and continuously monitoring the effectiveness of the plan to ensure your CHF patients are receiving the necessary care. It’s only by analyzing and testing these innovative approaches that hospitals can move closer to reducing their readmission rates for CHF.

About the author. Cheryl Anderson, senior consulting director in clinical advisory solutions, joined the Vizient team in 2010 after serving in a variety of clinical cost improvement and effectiveness roles. Possessing more than 35 years of experience in all areas of the health care industry, Anderson is particularly effective in leading clinical value analysis and performance improvement initiatives to increase the total value of care.

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