Lenore Blank, administrative manager of the heart failure team and pulmonary hypertension program at Hackensack University Medical Center, describes a three-tiered approach to keeping heart failure patients from returning to the hospital.
The goal is to decrease re-hospitalizations for this patient group, and empower and assist patients to develop self-management skills critical to keeping themselves out of the hospital. The outpatient center is modeled after the chronic care model. We have one heart failure physician and an office staffed with heart failure nurses. When patients call, they know they’ll be able to speak with a heart failure nurse, and that it’s an open-door policy. Patients know they can come in if they’re not feeling well, if they’re symptomatic, or if they are concerned about something they ate and want to check their Basic Metabolic Panel (BNP) level. We have very active, informed patients, and we try to give them the tools they need to succeed. For example, if they do not have a scale at home, we’ll provide one. We also have a support group that meets monthly, and we have added a consumer group as a spin-off of the support group. This allows us to check in with patients to find out what we can do better and whether we’re covering everything that’s important to them.
We have two nurses that job-share the telephone follow-up program. We developed the telephone follow-up program to reduce the gaps for patients who may not be eligible for or who refuse home care. The program provides education. The goal is to catch things early and then follow-up with the physician. Since they’ve formed healing relationships with the physician, the patients often want to come in. They want to meet the nurse they’d been talking to — the call may be one of the few calls they get in a week. The goal of the program is to decrease re-hospitalization by providing seamless care, including self-management skills and tools.
We developed the subacute care initiative because we saw the high readmission rate for patients discharged to skilled nursing facilities. We focused on one consortium of subacutes, and helped them with the management of these patients. The first thing we did was to put patients on a two-grams-of-sodium-per-day diet. We also made sure patients were being weighed daily. We offered nurses many in-service training programs, and went in once a week on rounds to check on these patients. We would make sure the nurses were brought in to look at a particular patient’s edematous legs or listen to their lungs. There’s been a huge improvement in this population.