Heart Failure Nurse Navigator Program Interventions Based on LACE Scores Reduces Inpatient Heart Failure Readmission Rates

Objective This presentation will identify top causes for Heart Failure (HF) patient readmissions and strategies for HF readmission prevention. The HF Nurse Navigator's role in preventing readmissions will be described. The implementation of the HF standard work discharge tool with seven interventions based on LACE scores used in the HF Nurse Navigator program will also be defined. Background Heart Failure continues to be one of the leading causes for hospitalization (national 30-day All-Cause HF readmission rates average: 22%). The goal of this community hospital is to decrease their average 30-day All-Cause HF patients' readmission rates from 21% to Problem Statement Increasing Heart Failure readmission rates due to avoidable readmission causes are unfavorable for our cardiac patients' quality of life and contribute to payment penalties. Methods The Heart Failure Nurse Navigator (HF NN) role was created at this hospital with the goal of decreasing readmissions and improving patient outcomes for the HF patient across the continuum of care. The HF NN is an expert clinician leader and a resource to the healthcare team in Progressive Care and other inpatient units through one-on-one HF education with the patient or significant other and assists in identification of services unique to each patient's needs for a smooth transition from hospital to home. New Nurse Leader roles such as an Advanced Practice Nurse Navigator equipped with Evidence Based knowledge and training is vital to oversee a specialized patient population in Acute Care; to design and implement interventions that can improve patient outcomes and decrease the patient's risk for readmission within 30 days. The HF NN in collaboration with the HF Team designed a Quality Improvement project implementing a HF Standard Work Discharge Checklist with seven patient interventions for the Acute Heart Failure patient. These interventions include: HF Teach-Back education; HF clinic referral; Outpatient pharmacy prescription delivery to bedside; Discharge Medication list education by the Pharmacist; Follow-up appointments made prior to discharge; Transitional Medical Clinic appointment within 5 days of discharge; and Home Health RN HF Medical Management. LACE (Length of-Stay, Acuity, Co-Morbidities and ED visits) scoring developed by Van Walvaren et al. (2010) was used to assess for readmission risk and to implement interventions specific for each HF patient based on their LACE score. Results This hospital's average 6-month All-Cause HF readmission rate decreased to 12.94% after the pilot of the HF Nurse Navigator program, vs. 21.1% pre-intervention. After the HF NN role was implemented, the average 6-month HF 30-day All-Cause readmission rate decreased by 39% postintervention over the 6-month pilot period. Conclusions The team-based HF Nurse Navigator interventions described when implemented for every Acute HF patient admission decreased HF readmission rates. There is a need to have 7-day a week coverage by a HF NN in an institution to ensure identification of services unique to each HF patient's complex needs. The HF NN can ensure that the HF patient has a smooth transition from hospital to home with these interventions, resulting in a decreased readmission risk.