EP13EO Nurses participate in interprofessional groups that implement and evaluate coordinated patient education activities.
Provide one example, with supporting evidence, of an interprofessional patient education activity that was associated with an improved patient outcome. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
Heart Failure Committee
BACKGROUND/PROBLEM
Heart Failure (HF) is a medical condition with high mortality and morbidity rates, and is the leading diagnosis of hospital 30-day readmissions. It imposes a high cost on the health system nationwide. Due to the Affordable Care Act, Medicare reimbursements are reduced for those hospitals that fail to achieve the national benchmark for 30-day readmissions. In December 2011, Homestead Hospital’s readmission rate was 22.58%.Therefore, the organization aggressively pursued and implemented strategies to meet fiscal accountability.
Interprofessional Group
One of the first tactics implemented was the creation of an interprofessional Heart Failure Committee in January 2012. The purpose of the committee was to improve processes and quality of care among HF patients by working collaboratively to discuss the guidelines, diagnoses, processes, and protocols across the entire hospital. Disciplines represented in this committee included Nursing, Emergency Department, Performance Improvement, Case Management, Cardiology, Internal Medicine, Pharmacy, Laboratory, Dietary, Rehabilitation Services, Respiratory Therapy, Clinical Informatics, Marketing/Community Education, and Emergency Medical Services/Miami Dade Fire Rescue. Since its inception, the committee members have continuously developed, implemented and evaluated multi-pronged approaches to improve care and lower HF readmission rates to below national benchmark. The committee looked at the literature for best practices as well as success stories from sister hospitals. The team decided to focus their more recent efforts on discharge education. HF discharge education of patients promotes self care and helps patient to identify problems early, which in turn increases the chances of early intervention and positive outcomes and reduces 30-day re-admissions (Paul, 2008).
Studies also showed that non-adherence with medications and diet is a leading factor in sodium and water retention and the cause of many 30-day re-admissions. To reduce these readmission rates, patients and/or care giver must be instructed on self-care activities during the very short, average length of hospital stay for this patient population. Repetition is required for the patient and/or care giver to understand the various ways to promote self-care, including monitoring weight, restricting fluid and sodium intake, regular use of medication, and monitoring signs and symptoms which could indicate worsening of the disease. The Heart Failure Society of America and The Joint Commission recommend that HF patients receive educational material as part of the instructions provided by the time of discharge. One challenge for hospitals to comply with this standard is whether the clinical team has sufficient time to plan individualized hospital discharge education and teach patients.
GOAL STATEMENT(S)
The goal of the interprofessional HF Committee was to identify and implement coordinated interprofessional patient education initiatives that would reduce 30-day readmissions from 35% to 25% or less.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Implementing Coordinated Patient Education Activities
In addition to the HF patient education booklet, symptom management, discharge call back, and real-time tracking of admitted HF patients that had been implemented, the interprofessional HF committee rolled-out coordinated hospital-wide patient education activities.
Follow up care Referrals: A nearby community clinic, Baptist Follow-Up Care, which was managed by Nurse Practitioner Adaeze Ohaeto, ARNP opened in August 2012. The Follow Up Care offers a comprehensive teaching program and primary care services until the patient is able to make a timely appointment with his/her PCP or until a medical home could be identified for follow-up appointments to continue the plan of care. Initially, the post-discharge referral required a doctor’s order. In January 2013, the clinic started accepting referrals without doctor’s order. This process facilitated clinical nurses’ referral of qualified HF patients to the clinic.
RN HF Teaching Script: The HF Committee also rolled out a teaching script for RNs that summarized all pertinent discharge self-care behaviors on one page in January 2013.
. The objectives of the RN teaching script were to;
- Deliver the same content to each patient
- Verify patient’s understanding
- Review the top four self care practices to prevent heart failure readmission
- Improve self-care adherence
Nurses used the script on each shift for HF patients. Since reinforcement was important to retention, this education was given on a daily basis by each nurse at the specified times. Each RN used the teach back method to ensure patients and/or families verbalized an understanding of the topic at that moment. Baker developed an online learning module on “HF Patient Education – Teaching Tools” for the nurses in January 2013.
Exhibit EP13EOa: “HF Patient Education – Teaching Tools” Learning Module Screen Shot
Heart Failure Support Group. The HF committee also instituted monthly HF support group meetings in May 2013 held at the hospital campus. The support group was participated in by an average of 2-7 patients and their care givers monthly. Different subject matter experts, mostly from among the HF committee membership, would facilitate the discussion and taught the attendees about the disease, low sodium diet, reading food labels, importance of medication compliance, and smoking cessation. An open forum at the end allowed the participants to discuss their particular issue with clinical experts. They seemed eager to improve self-care and return to their baseline health status.
Heart Failure RN Educator: Since November 2013, HF Nurse Educator Audreen Arries-Hjerpe, RN conducted daily rounds on all new patients 4 days per week. She spent approximately 30 minutes per intervention using the HF teaching guide to touch on essential points concerning HF and use the teach-back technique. Arries-Hjerpe then conducted a 4-month audit to evaluate if the teach-back method was effective. The audit revealed that the teach back technique was effective as patients were able to recall some knowledge of self care activities.
Interdisciplinary Patient Education Record (IPER) Performance Improvement (PI) Nurse Leticia Berrones, RN and her team submited a daily list of all HF patients in the hospital, and Clinical Informatics Specialist Cathy Caron, RN provided a list of all HF patients who were readmitted within 30 days. Caron sent this patient list to all patient care areas, nurse clinical educators, pharmacists, and HF RN educator at least three times per week. The HF committee also requested Caron to design prompts for HF teaching points in the IPER section of the electronic medical record. This provided a guide for the interprofessional team and streamlined the HF patient education. All disciplines documented their findings on IPER in the electronic medical record. Clinical nurse educators conducted retrospective audits in April 2013 to monitor staff compliance and quality of teaching.
PARTICIPANTS
The members of the interprofessional HF Committee were:
Name/Credentials |
Title |
Department |
Role in the Team |
Joan Baker, MSN, RN, CCRN, CNRN, CCPC |
Patient Care Manager and Cardiovascular Care Coordinator |
ED |
Committee Chair |
Audreen Hjerpe, RN |
HF RN Educator |
ED |
Member |
Rosemary K. Lee, DNP, ARNP,ACNP-BC,CCNS, CCRN |
Clinical Nurse Specialist |
Critical Care |
Member |
Sandy Jones, BSN, RN, CMSRN |
Clinical Nurse Educator |
3 South |
Member |
Beverly Johnson, BSN, RN, CMSRN |
Clinical Nurse Educator |
MS4 |
Member |
Pamela Burney, RN |
Clinical Nurse |
Nursing Administration Clerical |
Member; Discharge Call RN |
Kelly Vasquez, RN, ONC, CMSRN |
Clinical Nurse |
Nursing Administration Clerical |
Member; Discharge Call RN |
Margo Archer, RN |
Clinical Nurse |
Nursing Administration Clerical |
Member; Discharge Call RN |
Leticia Berrones, RN |
PI Nurse |
PI |
Member; Data management |
Cathy Caron, MSN, RN |
Clinical Informatics Specialist |
Clinical Informatics |
Member; IT Liaison |
Ann Marie Allen, MSN, RN, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Member |
Patricia Brodie, RN |
Manager |
Case Management |
Member |
Winifred Pardo, RPh, PharmD |
Clinical Pharmacist |
Pharmacy |
Member, |
Juliette Urbina, RPh, PharmD |
ED Clinical Pharmacist |
Pharmacy |
Member |
Mary Shaw, MS, RD, LD/N |
Dietitian |
Dietary |
Member and Support group facilitator/instructor |
Kelly LaRocco- Keefe MPH, RD, LD/N |
Dietician |
Dietary |
Member and Support group facilitator/instructor |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Executive Sponsor |
Aracely Olvera, BSN, RN, CMSRN |
Clinical Nurse Educator |
MS5 |
Member |
Eda Avila, BSN, RN, RRT |
Clinical Nurse Educator |
Respiratory Therapy |
Member |
OUTCOME(S)
Evaluating Impact of Coordinated Patient Education Activities
Using Kirkpatrick’s model, the coordinated patient education activities were evaluated as follows:
Reaction: The nurses articulated that the available resources made them better equipped to deliver patient education on HF medications and diet. Patients who participated in the HF support group reported that they were able to better handle the challenge of adhering to a low salt diet, fluid restriction, and smoking cessation due to the one-on-one interaction available to them during support group meetings.
Learning/Knowledge: The patients and care givers were taught life style changes necessary for HF patients/families to be successful in self care management. Teach back audits demonstrated an increasing ability to recall self care management that was taught by the nurses.
Behavior: The interprofessional team was required to document content and outcome of HF topics taught to the patient and or families using the IPER to communicate teaching intervention by all disciplines. A monthly audit of IPER showed that the documentation of patient education on key self care topics was steadily increasing.
Results/Outcomes – Studies show that a multi-faceted approach is important to address the 30 day readmission rate of HF patients. The HF committee has seen a slow yet steady decline in 30-day readmission rates for HF patients over the last 12 months which they attributed to the multifaceted and coordinated interprofessional patient education activities they implemented.
Exhibit EP13EOb: Homestead Hospital HF 30-Day Readmission among All Payers
Analysis: The graph shows that after various interventions were implemented to assist HF patients in self-care post discharge, the readmission rates decreased and were maintained below the 25% goal for 3 consecutive quarters.
References
Paul S. Hospital discharge education for patients with heart failure: what really works and what is the evidence? Crit Care Nurse. 2008 Apr;28(2):66-82
Aliti GB, Brun AO, Domingues FB, Rabelo ER, Ruschel KB. What to teach to patients with heart failure and why: the role of nurses in heart failure clinics. Rev. Latino-Am. Enfermagem. 2007; 15(1):165-70.
Albert NM. Improving Medication Adherence in Chronic Cardiovascular Disease. Crit Care Nurse. 2008 Oct;28(5):54-65.
Paul S. Hospital Discharge Education for Patients with Heart Failure: What Really Works and What Is the Evidence? Crit Care Nurse. 2008;28(2):66-82
Carroll KC, Gardetto NJ. Management Strategies to Meet the core heart failure measures for acute decompensated heart failure. Crit Care Nurs Q. 2007 Oct-Dec;30(4):307-20.
Aaronson KD, Cody RJ, Johnson ML, Koelling TM. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111(2):179-85.
Anderson MA, Brown SM, Brown-Benn C, Bryant PJ, Dusio ME, Levsen J. Evidenced-based factors in readmission of patients with heart failure. J Nurs Care Qual. 2006 Apr-Jun; 21(2):160-7.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP13EOa: “HF Patient Education – Teaching Tools” Learning Module Screen Shot
Exhibit EP13EOb: Homestead Hospital HF 30-Day Readmission among All Payers