With the implementation of a grant-funded program to reduce hospital readmissions for elderly patients with heart failure, the University of California, San Francisco (UCSF) Medical Center was able to reduce rates of heart failure readmissions over a two-year period by 46 percent within 30 days of hospital discharge and by 35 percent within 90 days.
According to The Commonwealth Fund's recent case study on the UCSF Medical Center program, the hospital initiated the program in late 2008 in collaboration with the Institute for Healthcare Improvement and with funding from the Gordon and Betty Moore Foundation.
Program coordinators were hired to provide enhanced patient education and follow-up care connections to promote the elderly patient's successful transition to home or to skilled nursing care.
The program started out with a target population of Medicare patients age 65 and older (average was age 80) hospitalized with a primary or secondary diagnosis of heart failure (representing approximately 700 admissions during the year the program began).
"They worked systematically over time to build a program with several key components," said Douglas McCarthy, senior research advisor at The Commonwealth Fund. "They use a teach-back method with patients so they can know about their conditions – testing them to see what they know and tailoring education to their actual needs. They build it up overtime so it isn't too overwhelming for patients. They follow up with phone calls after discharge and create options for them if they can't see a primary care physician. They have home visits for patients at a very high risk. Also, making sure there's a consistent approach to all patients. Patients know about their conditions and afterwards there are good handoffs and transitions."
According to McCarthy, the program consists of two heart failure program nurse coordinators, supported by a multidisciplinary team comprising a cardiovascular service line director, hospitalists, cardiologists, clinical nurse specialists, case managers, social workers, pharmacists, dieticians, chaplains, educators, primary care physicians, skilled nursing facility staff, home care nurses and outpatient nurse practitioners.
The hospital also created a virtual care team, McCarthy said. "They use email in a creative way to let everyone in outpatient care, including primary care physicians, know where their patients are at and when they were discharged so everyone is in the loop. This helps them not come back unnecessarily."
McCarthy hopes that while every hospital institution varies in the way it handles readmissions, they will look at the successes of the UCSF Medical Center program, which has now become self-sustaining and is being expanded to include all adult patients with heart failure.
"Not every hospital can hire coordinators but are there lower cost ways to create this approach? Communicating with post acute care providers is important. It's something that everyone needs to work together on to focus on the entire care episode," he said. "It improves quality of life for patients and saves money."
[See also: Readmission costs even higher than suspected]