Did you know that Heart Failure (HF) is the leading cause of hospitalization among people with Medicare? Plus, HF costs our nation over $17 billion each year and one in five Medicare patients with HF are readmitted with 30 days.
National hospital rating systems pay a great deal of attention to how well organizations treat HF. By improving our HF performance, we can improve our national rankings, save money, and keep patients well and out of the hospital!
At the hospital and neighborhood outpatient centers we use a multi-disciplinary approach to improve our readmission and mortality rates. The team includes clinicians from both inpatient and outpatient settings and from several departments. Through the LEAN process and the BCBSM BOOST (Blue Cross and Blue Shield of Michigan Better Outcomes for Older Adults through Safe Transitions) initiative, we identified ways to improve the discharge process and improve care:
- Metro improved patient education by providing nurses with a flip chart to review with patients prior to discharge and by providing each HF patient with a calendar and magnet to help them manage their condition at home
- All HF patients have a follow-up appointment scheduled with their physician and documented on their After Visit Summary (AVS) before they are discharged from the hospital
- All HF patients have an initial home care evaluation
- AVS documents for HF patients contain key elements of information that help patients and their primary care physicians manage HF from the physician’s office instead of the hospital
- For patients who are discharged to Skilled Nursing Facilities (SNFs), Metro improved communication between the hospital and the SNFs to more clearly outline what follow-up care the patient needs
- Metro improved communication in the hospital by redesigning the daily hospitalist meeting to include cardiology and a discussion of what follow up care each HF patient may need at discharge
- Two case managers were assigned to Level 5 to manage the discharge needs of all HF patients
- Metro redesigned the discharge summary so that outpatient physicians can more clearly understand what was done for the patient while he/she was in the hospital and what follow-up care the patient needs
- Metro calls all patients 24-48 hours after discharge to ensure they are doing well at home or in their SNF
- While none of these steps on their own seem like a significant change, together they are significantly improving outcomes for our HF patients. As we continue to monitor how well Metro’s HF patients manage, we will continue making changes that can improve the lives of our patients.