Improving Heart Failure Patient Transitions of Care and Reducing Readmissions with a Structured Hand-off Process

Purpose Heart failure (HF) patients have the highest 30-day readmission rates of all Medicare discharge diagnoses. Excessive readmissions can result in reduced reimbursement (lost revenue) under pay-for performance programs. Inadequate discharge preparation and problems with care transitions increase risk of readmission. Our purpose was to reduce readmissions of HF patients by improving transitions of care with a novel, structured and directive discharge handoff process. Objectives Our aim was to improve HF patients transition from hospital to homecare by providing a structure to ensure that: 1) HF patients' discharge readiness was assessed prior to discharge; 2) risk factors for readmission were systematically evaluated and addressed prior to discharge, and 3) communication and collaboration between nurses from the inpatient and homecare setting was facilitated. Methods Input was sought from clinical nurses on our hospital's HF unit and from homecare nurses from the units preferred (and most utilized) vendor. At a meeting, nurses from both settings were polled using audience-response technology, about: 1) their perceptions of the factors that contributed most to HF patients' readmission; 2) what type of communication between settings would improve transitions and reduce readmissions, and 3) current communication practices between settings. Nurses perceptions were combined with known risk factors for readmission from the HF literature to a create an in-person, bedside handoff between inpatient nurse and homecare intake nurse, performed on the day of discharge, in the presence of the patient, requiring completion of a checklist that forces review of risk factors for readmission (from the literature and polling results). Each item on the checklist links to specific actions to be taken for problems identified, prior to discharge. The checklist is embedded in a one-page form, which includes key metrics (most recent EF and weight) and contact information of the discharging RN, NP, and patient PCP, to make communication easy for the homecare RN. The process takes 5 minutes to complete. Both nurses sign the form. A copy is forwarded to the homecare field nurse, and one is kept on the unit for reference. The process was developed in late 2015 and implemented over several months in early 2016. Results Readmission rates for the HF unit were evaluated for 12 months prior to implementation (1/1/2015-12/31-2015) and for 12 months following implementation (5/1/2016-4/30/2017) allowing 4 months for complete integration into practice (1/1/2016-4/30/2016). For the 12 months prior to implementation the unit's HF patient readmission rates were: Unit rate=17.4% (79 readmits/455 HF discharges); discharged to homecare=20% (49/241); regular discharge=13% (20/156.). For the post implementation 12 months, HF readmit rates were: unit= 12.9%(67/519); homecare=14%(47/256); regular discharge=11%(22/202.) Readmission rates were substantially reduced in the post-implementation period, although the total number of HF discharges was greater than in pre-implementation. Feedback from nurses was positive. Subsequently, the vendor implemented the handoff in other hospitals in NYC. Conclusions A structured handoff at the time of discharge, between nurses from two different settings, can contribute to substantial reduction in HF patient readmissions. This nursing practice improves patient outcomes, and by reducing readmission, prevents revenue loss, in effect, generating value. Table/Image 171627-2-54356.pdf Table/Image: Primary Author Registrant ID: 5632479 First Name: Arlene Last Name: Travis Phone Number: 9179453226 E-mail: arlene.travis@mountsinai.org Credentials ANP-BC, CHC, CHFN-K Affiliation Name: Mount Sinai Hospital Affiliations Address 1: 3210 Arlington Ave. Address 2: Apt. 6H City: Bronx State: NY Zip Code: 10463