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Reducing Hospital Admissions for Patients with Heart Failure by Implementing the Chronic Care Management Framework: A
Alexis Koutlas1, Peggy Jenkins
1Director of Integrated Care Management (Dr. Koutlas), Embright, LLC, Seattle, WA akoutlas@hotmail.com.
Objective:
To reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication.
Background:
Heart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction.
Methods:
A nurse led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum.
Results:
Hospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05).
Conclusion:
Improved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000.
Implication For Nurses:
Nurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.
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