For elderly patients with heart failure, a collaboration between Kaiser Permanente Colorado Region and the Visiting Nurse Association in Denver contributed to a 24% decline in readmissions while improving patient knowledge and promoting good self-management behaviors.
The program was profiled on the Agency for Healthcare Research and Qualitys Innovations Exchange site (www.innovations.ahrq.gov).
For elderly patients with heart failure who need home-based skilled nursing care after hospital discharge, Kaiser clinicians provide a referral to the Visiting Nurse Association. The VNA sends a home health nurse to visit within 48 hours of discharge to perform medication reconciliation and initiate self-management education.
The nurse visits another five to seven times over the next four to seven weeks to offer education based on a standard guideline that emphasizes goal setting; symptom identification; and specific self-management skills, including appropriate diet, daily recording of weight and blood pressure, and maintenance of dietary intake and general health logs.
The VNA nurses give Kaiser care coordinators regular updates and notify them of any signs of an exacerbation, allowing physicians to intervene on a timely basis.
Coordinators reported that in addition to the 24% reduction in all-cause readmissions during the first 18 months, the program improved patients’ knowledge of various components of heart failure care and helped them employ good self-management behaviors such as weight and blood pressure measurement and medication and dietary adherence.
To read more about implementation of the program, visit www.innovations.ahrq.gov/content.aspx?id=3680.