Early Home Visits by a Registered Nurse Care Manager with Heart Failure Patients.

摘要

Strategies focused on 30 days in the life of a patient with heart failure will have limited impact on the burden that heart failure will have nationally or individually. The broader landscape of readmission risk underscores the need for a more comprehensive approach to heart failure management. Care management with a registered nurse demonstrated efficiently coordinate care. Home visits address the peaks of risk in the post-discharge transition and palliative phase while providing longitudinal support. The purpose of this study is to substantiate that early home visits and telephone followup with a registered nurse after discharge from the hospital will decrease the readmission rates of heart failure patients. The interventions used were face-to-face encounters, follow up telephone phone calls, a quality of life self-report tool and a medication reconciliation tool. This study utilized a secondary analysis of data collected with a state-funded grant to decrease readmissions of heart failure patients at a local 700-bed, not-for-profit hospital. The participants were identified based on their lack of insurance or being underinsured with Medicaid. A newly dedicated heart failure unit with 10 dedicated beds was opened in 2011. A team of case managers, nurses, and physicians responsible for referring the patients who met certain guidelines were referred to the care manager. If the patient met the insurance criteria and was NYHF Class III or IV, the patient would then be eligible for a care manager and pharmacist to assist with the transition home. Study results concluded that there were definite advantages to both these services in decreasing readmissions.