University:
Boston University
Course:
SAR HP 151 | Introduction to Health Professions
Academic year:

2020
Views:

256

Pages:

19
Author:

Kristen Singleton

Reducing HF Readmissions: The Creighton Story Using Project RED Objectives zTo identify the key initiative to reduce HF readmissions zTo list the components of the Project RED Model zTo describe initiatives to improve care transitions points including discharge Project RED Re-engineering Discharge z Educate the patient about Dx during stay z Schedule appointments for follow up care z Organize post discharge services z Confirm medication list z Review steps what to do if problem arises z Expedite transmission of discharge info to next provider z Assess degree of patient understanding of discharge information – repeat in own words z Provide written discharge transition plan of care z Provide telephone reinforcement of discharge plan within 2-3 days of discharge CUMC Discharge Transition to Community External Internal Meet with physician groups BCBS discharge Follow-up Discharge Instructions Patient Understanding Of Information Meet with Nursing Homes Meet with CHF clinic Set-up Physician appt For Patient Clinical Nurse Leader role impact Meet with UniNet Follow up Care Meet with Cardiac Center Discharge Info To physician Phone call Follow-up With Patient Pre-Hospital Emergency Care Drill down on processes CUMC Discharge Transition to Community Internal Discharge Instructions Patient Understanding Of Information Set-up Physician appt For Patient Clinical Nurse Leader role impact Discharge Info To physician Phone call Follow-up With Patient CHF Team Formed Tenet Readmission Collaborative CHF Team z Formed March 2010 z Multidisciplinary {Nursing {Physicians {Case Management {Social Work {Nutrition {Pharmacists {Cardiac Center {CHF clinic {Emergency Care Initiatives zAdmission {Assess/identify factors related to readmission {Identify CHF admits {Heart on chart - room {Lasix list review {Literature review {Focus on reasons for return to prevent readmissions {Use self-care behavior tool – design discharge Initiatives continued zPatient education ‘Heart Failure Zone’ zReadmission case review zExplore discharge resources ASAP zFocus on discharge readiness zFocus on patient understanding – AskMe3 {What is the main problem? Able to answer {What do I need to do? {Why is this important to do this? Heart Failure Zones EVERY DAY: •Weigh yourself in the morning before breakfast, write it down and compare to yesterday’s weight. EVERY DAY •Take your medicine as prescribed. •Check for swelling in your feet, ankles, legs and stomach. •Eat low salt food. •Balance activity and rest periods. Which Heart Failure Zone are you today? GREEN, YELLOW or RED? ALL CLEAR – This zone is your goal Your symptoms are under control. You have: GREEN ZONE •No shortness of breath. •No weight gain more than 2 pounds (it may change 1 or 2 pounds some days). •No swelling of your feet, ankles, legs or stomach. •No chest pain. Heart Zone CAUTION - This one is a warning Call your doctor’s office if: •You have a weight gain of 2-3 pounds in 1 day or a weight gain of 5 pounds or more in 1 week. •More shortness of breath. YELLOW ZONE •More swelling of your feet, ankles, legs, or stomach. •Feeling more tired. No energy. •Dry hacky cough. •Dizziness. •Feeling uneasy, you know something is not right. •It is harder for you to breathe when lying down. You are needing to sleep sitting up in a chair. EMERGENCY RED ZONE Go to the emergency room or call 911 if you have any of the following: •Struggling to breathe. Unrelieved shortness of breath while sitting still. •Have chest pain. •Have confusion or can’t think clearly. Initiatives continued zFollow up appt set for patient all discharges {Appointment made for patient 65% {Follow up on weekend discharges Appointment within a week best practice { Working with each physician individually if need Initiative continued zCHF class post hospitalization launched Fall 2010 with the Cardiac Center { Class held once a month { Taught by multidisciplinary team: Nurse Practitioner , Dietitian, and pharmacist { Referred upon discharge/scheduled { No cost to the patient Initiatives continued z Medication list accuracy with RN & clinical pharmacist, review list with patient/family z Provide scale for home use { Need based { Order through our Staples national contract z Phone Call follow-up within 2-3 days of discharge {Focus on keeping appointment – reinforcement {Medication – prescription – answer & reinforce schedule {Clinical Nurse Leader target HF population {Expanding, hard wiring process, data collection {Expanding support information for the patient need/helps {Post card follow up if unable to reach patient after 3 calls Transition to Community zSelf management, HHC….. zStudent Nurse visit ongoing zSkilled nursing facility with like CHF management goals {Transition of information {Weight oversight critical {Staff education {Use HF zone education tool New Discharge Instruction Patient Specific Information.. Plan of Care Transition Transition to Skilled Care zMet with skilled facility partners {Three meetings with SNF and QIO representatives {Identify information needed/wanted {Refined list, determined if data system generated zSkilled facility wish list of information zGoal minimal work by nurses at CUMC and provide clear information for receiving facility to also include HHC going forward Transition to Community…. Information Requested Four Reports Designed System generated Win – Win – Win !!!! Receiving Facility/HHC – Physician – Nurse – Patient Design Complete – Education Completed • Last 24 hr snap shot • Today’s Assessment • Discharge plan • Appointment • Follow up • Calls • Medication List • Ready to fill Next Steps - Community transitions points CUMC Skilled Facility Or HHC Or Home ?????? Students Physician Visit CHF clinic 1. Work with HHC Agencies 2. Establish program with Creighton SON 3. Focus on readmitting factors – DNP project 4. Expand phone call follow-up 5. Info to PCP evaluate 6. Improve/refine processes focus on: • Medication management • Symptom management • Follow-up appointment Exceed set readmission benchmark

Creighton Story Using Project

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