Healthy Heart Initiative: An APN Model of Care for Reduction in HF Readmissions
Kutzleb, Judith Ann
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(41st Biennial Convention) Heart Failure (HF) continues to be a major public health problem associated with high medical resource consumption, frequent and costly hospital admissions, and ultimately high mortality rates. Randomized control trials (LOE I/II) showed that patient education for disease self-management in concert with a multidisciplinary approach can improve clinical outcomes and reduce the number of admissions for worsening heart failure and/or all cause death when compared to usual care. The purpose of this program was to implement practice change for HF patient management in the acute care setting. The protocol includes patient referral to the Health Heart Initiative APN team upon admission to the hospital for individualized patient education and disease specific self-management. Case management, social service and nutrition consults are initiated within 24 hours of hospital admission for comprehensive discharge planning. Patients enter the program by either physician referral, nursing referral, or through the core measure data bases. Within 24-48 hours of admission, the Health Heart Initiative APN assesses the patients' understanding of HF, and then begins the individualized education process on life-style modifications (low sodium diet, exercise, daily weights, and medication management) for disease self-management. Prior to discharge patients were monitored by the APN through weekly telephone follow-up for 30 days; then bimonthly for 30 days; then monthly for 30 days. The APN directed non-pharmacological patient management in concert with multidisciplinary team approach decreased readmission rates from 23% to 8% over 1 year. A significant portion of patient crises were avoided with improved compliance to protocols due to close patient monitoring. An APN driven HF program has proved to be a cost-effective means to decrease readmissions, and improved disease self-management in people with HF.