Heart failure (HF) is a diagnosis that often comes with a risk of readmission to the hospital. And, for heart failure patients going to a skilled nursing facility (SNF) following their hospital stay, the risk is even greater so it's important they receive consistent, proactive care to avoid future readmissions.
As part of an initiative to reduce hospital readmission rates in patients with heart failure, NCH's HF task force developed a consortium involving area SNFs last fall. "Our goal was to start a productive discussion about how we could improve communication and planning in an effort to provide HF patients with the best care possible," explains Bonnie DeGrande, director of Cardiovascular and Diabetes Services.
"The outcome of this meeting was the development of a HF discharge order set for patients being transferred to SNFs – something that hasn't been done before," says Karolee Fill, RN, APN, who coordinates care for NCH's HF patients. "The order set is based on standardized, evidence-based guidelines that address the specific needs of this patient population."
Based on a nurse-driven protocol, the new HF discharge order set promotes ongoing physical assessment to prompt early intervention when needed, thus preventing a hospital readmission. In addition to the routine transfer orders, directions such as when to call the doctor, parameters for titration of diuretics, recommended diet and activity, oxygen, and diagnostics are included in the order that's signed by the physician and initiated upon arrival to the SNF.
"The new HF discharge order set is available to all physicians via CareLink under pre-printed orders," explains Fill. "Our next step is to begin educating SNF staff on how to use the new order set."
DeGrande says that the Transitions of Care consortium will expand to other patient populations over time. "The SNFs are very interested in expanding this to other diagnoses," she notes.
Building strong relationships, avoiding readmissions and improving patient quality of care are the goals of this growing partnership with the SNFs. According to DeGrande, the most recent hospital Compare data from CMS indicates that our readmissions are below the national average for HF patients. "Based on this new information, it is even more imperative that we aggressively pursue strategies that facilitate collaboration with the SNFs to improve patients' care once they leave the hospital, thus reducing avoidable readmissions."