Education, Teaching, and Quality Improvement |

A Multidisciplinary Initiative to Improve Transitions of Care for Veterans With Congestive Heart Failure to Reduce Hospital Readmissions and Lengths of Stay FREE TO VIEW

Shoma Singh, MD; John Ulahannan, MBBS; Pratik Dalal, MBBS; Dean Humphreys, NP; Joan Mitchell, MD; Changwan Ryu, MD
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SUNY Upstate Medical University, Syracuse, NY

Chest. 2013;144(4_MeetingAbstracts):539A. doi:10.1378/chest.1705046
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SESSION TITLE: Cost and Quality Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: Our goal was to improve transitions of care among our veterans with congestive heart failure (CHF) by collaborating with our cardiology colleagues to develop a dedicated CHF clinic managed exclusively by a nurse practioner (NP). Through this clinic, we aimed to empower our veterans in their disease self-management by providing education that emphasizes medication adherence and symptom awareness, which we hypothesized to reduce 30-day hospital readmissions and lengths of stay.

METHODS: After we admit a veteran with a diagnosis of CHF (defined by diagnosis related group (DRG) 291, 292, or 293), we alert our NP for a clinic referral. During the hospitalization, our NP meets with the veteran to provide CHF education aimed at anticipatory guidance for self-management with our “Heart Failure Action Plan.” This educational tool reviews the physiology of CHF, discusses the role of medications, and encourages symptom awareness. In addition to the follow-up appointment with the veteran’s primary care physician or cardiologist, our NP will provide the veteran either phone-call or clinic visit, whichever form of contact that the veteran can accommodate, within 30 days of discharge. During the phone call or clinic visit, our NP reviews the medications, the presence of new symptoms, changes in weight, and any new concerns since being discharged from the hospital.

RESULTS: The overall readmission rate between the pre-clinic cohort (19.8%) and clinic cohort (18.4%) was not statistically significant (Fischer Exact Test (FET) p=0.429). The CHF readmission rate between the pre-clinic cohort (8.3%) and clinic cohort (7.8%) was also not statistically significant (FET p=0.510). The average LOS between the pre-clinic cohort (6.09 days) and clinic cohort (4.68 days) was statistically significant (t-test p=0.04).

CONCLUSIONS: We found a modest decrease in readmission rates, and as we continue to enroll more veterans, we expect to experience further reductions. We also saw a significant reduction in LOS, which we attribute to higher patient confidence and empowerment with discharge planning through the educational and follow-up services offered by our clinic.

CLINICAL IMPLICATIONS: With these promising benefits to patient care, we plan to expand the scope of our clinic to encourage more veterans to enroll. Incorporating into the discharge process a transition of care model that promotes disease self-management and close follow-up care through these physician extender services can be vital to optimizing chronic disease management.

DISCLOSURE: The following authors have nothing to disclose: Shoma Singh, John Ulahannan, Pratik Dalal, Dean Humphreys, Joan Mitchell, Changwan Ryu

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