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Strategies to Decrease CHF Readmissions

Strategies to Decrease CHF Readmissions. Beverly Jameson RN, MSN Nurse Manager Cardiac Telemetry Greenville Memorial Medical Center. Introduction. Heart Failure has reached epidemic proportions

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Strategies to Decrease CHF Readmissions

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  1. Strategies to Decrease CHF Readmissions Beverly Jameson RN, MSN Nurse Manager Cardiac Telemetry Greenville Memorial Medical Center

  2. Introduction • Heart Failure has reached epidemic proportions • Heart Failure is expensive • Frequent readmissions

  3. Causes for Readmission (in order of frequency) • Non-compliance with medication regimen, diet, and/or lifestyle • Progression of underlying cardiac disease • Co-morbid conditions (obesity, diabetes, hypertension, renal disease)

  4. GMMC Strategy: Decrease Readmissions • Cohort CHF patients to the Cardiac Telemetry Unit • Implement a system to review CHF Core Measure compliance daily • Improve medication reconciliation using Core Measure discharge planning standards • Improve patient education to decrease readmissions • Improve the timeliness of physician follow-up at discharge • Involve Palliative Care earlier in the disease course • Solicit the buy-in of the CHF Team

  5. Multidisciplinary ProcessTeam Collaboration • Oversight of the clinical course • All non-ICU CHF patients are assigned to 4C • Review the core measures on each CHF patient daily • Medication Reconciliation (Pharmacy Pilot Project) • Standing order for HeartLife and Case Management

  6. Multidisciplinary Process • Weekly CHF Rounds • Monthly CHF Action Team • Discharge Nurse • Home Health Telemonitoring • Post-Acute Care Management • Scales at discharge (GHS Auxiliary) • Staff Education at SNF

  7. CHF Readmissions • 3rd consecutive year rated “Better than National Average” • Sustained decrease in CHF readmissions • All-Cause readmission rate of 19.7% (national avg 24.8) • 8th lowest overall rate in the country • Readmission rate for CHF is 6.1% • All-Care Measure score is 98.08%

  8. Data Analysis

  9. Data Analysis

  10. Data AnalysisSecondary Diagnosis

  11. Lessons Learned • Staff buy-in is crucial (bedside nurses, Unit Council) • Team approach is crucial – CHF management is multi-faceted • Have opportunities to increase use of Palliative Care, provide discharge nurse 7 days/week, increase frequency of multidisciplinary CHF rounds, increase available technologies

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