Reducing heart failure hospital readmissions from skilled nursing facilities

Area of Science:

• Healthcare Management
• Nursing Practice
• Cardiology

Background:

• Heart failure readmission rates are a core measure for the Centers for Medicare & Medicaid and the Joint Commission.
• A 30% 6-month readmission rate for heart failure patients discharged to skilled nursing facilities (SNFs) was identified at an urban Midwestern medical center.

Purpose of the Study:

• To decrease the readmission rate for heart failure patients discharged to SNFs.
• To address a gap in follow-up care for patients discharged to SNFs, as opposed to home.

Main Methods:

• Implementation of a nurse case management process involving follow-up phone calls within 48 hours of discharge to SNF registered nurses/licensed practical nurses.
• Verification of key discharge orders, including daily weights, sodium-restricted diet, appropriate diuretics, and timely primary care provider follow-up.

Main Results:

• The readmission rate decreased from a baseline of 30% to an average of 11.32%.
• Improved continuity of care and clarification of discharge orders were achieved.
• Enhanced communication and strengthened relationships between hospital and SNF nursing staff.

Conclusions:

• A simple, innovative nurse case management process significantly reduced heart failure readmissions from SNFs.
• Improved communication and partnerships between inpatient and SNF providers led to reduced transcription errors and better patient health outcomes.