Imagine becoming extremely ill, being hospitalized and diagnosed with a chronic condition that you may not know much about, and days later, being sent out on your own with prescriptions and well wishes.
For some patients, this is a recipe for disaster that results in additional medical emergencies and return stays in the hospital. For congestive heart failure, which affects about 4.8 million people in the U.S., readmission rates at UC Health University Hospital are about 30 percent, with the national average at about 24 percent.
In an attempt to lower this number, the Robert Wood Johnson Foundation began an initiative in the summer of 2010 to reduce readmissions for heart failure nationally.
Stephanie Dunlap, DO, director of UC Health’s heart failure program, was appointed project leader for the initiative at University Hospital. As a patient-education arm of this initiative, a team of nurses and staff at University Hospital launched a program in February to educate those with heart failure about caring for themselves after leaving an in-patient setting.
"We call our team ‘Your Heart’s Connection,’” says Justin Foreman, clinical manager of 6 South (Cardiac Telemetry Unit) in the hospital and a member of the team.
Mary Collier, clinical nurse leader of the Cardiovascular Intensive Care Unit, and Monica Worrell, nurse clinician in 6 South, are the team leaders. Foreman says the team is a care support resource, focused on educating the patient.
The team visits patients in their rooms prior to discharge and hands out resource packets to help them manage their health at home.
"We take the time to go through the materials, allowing patients to ask questions,” he says, adding that the packet includes information about the importance of patients weighing themselves daily as well as dietary management, prescription education and follow-up care.
The team has also created a hotline, available for patients to call if they have questions or need further education once they’ve left the hospital setting.
"Someone is on-call to offer support and education to optimize the best possible outcomes for our patients,” Foreman says.
"Their lives could depend on it.”
Dunlap says patient education is key in bringing down the readmission rates and improving overall patient health.
"Clearly, the most expensive part of caring for patients with heart failure is during hospitalization,” she says. "With nearly a 30 percent readmission rate, the drain on public health dollars is tremendous.
"With the Robert Wood Johnson Project, we aim to not only increase the health and well being of the patient with heart failure, we also stand to decrease our public health dollars for this dreadful disease.”
The team is now collecting data to be announced widely in coming months in hopes of showing that this patient-centered initiative is making a difference in care at University Hospital.