REDUCING)CHF)READMISSIONS)

Sheri&Harrison,&BSN,&AU&MSN&Student&

PICO&QUESTION:&
In&older&patients,&greater&than&65&years&of&age,&who&have&been&admitted&in&an&acute&care&facility&with&congestive&heart&failure,&&
how&does&an&appointed&discharge&educator&representing&a&multidisciplinary&team&approach&&
as&compared&to&regular&routine&care&for&the&management&and&prevention&of&readmission&of&these&patients?&&
METHODS)

BACKGROUND+

RESULTS)

RESULTS)

(GRADE A RECOMMENDATIONS)
Implementation)of)a)of)Discharge)Educator)

!Goal&of&DE&is&to&educate&and&advocate&for&the&patient&
to&best&prepare&him/her&and&the&patients&designated&
family&members&for&discharge&and&medical&success&
following&discharge.&&&&&
!DE!IN!A!NUTSHEL..&&Organize&and&teach&the&discharge&
plan&that&has&been&developed&by&the&multidisciplinary&
team.&&Identify&and&rectify&gaps&in&the&discharge&plan&
and&add&them&to&the&plan.&&Identify&patient&barriers&to&
discharge&plan&and&strategies&to&overcome.&

!10&patients&(50% women, 50% men, 60% white, 40%

black, 40% Class II, 60% class III heart failure) with the
average age of 72 (+/-2.30) years) were&enrolled&who&
met&criteria&&
!Criteria&&Medicare&patients&with&diagnosis&&of&class&IINIII&
heart&failure&&who&have&recently&been&admitted&into&an&
acute&care&facility.&&&

!Education&provided&to&patient&prior&to&discharge&&&
!Patients&were&provided&&with&an&After&Hospital&Care&
Plan&(AHCP).&&This&ACHP&was&detailed&personalized&
information&that&included&medication,&diet,&weight&
monitoring,&diagnosis&education,&and&follow&up&
appointments.&&TeachNback&method&was&used&to&
conrm&understanding.&

The)American)Heart)Association)reports)that)out)of)a)million)people)that)are)
hospitalized)each)year)with)heart)failure,)about)250,000)will)be)readmitted)
within)30)days)!!))
The)Aordable)Care)Act)authorizes)Medicare)to)reduce)payments)to)acute)
care)hospitals)with)excess)readmissions)that)are)paid)under)CMSs)inpatient)
prospective)payment)system)beginning)October)1,)2012.)The)program)initially)
focuses)on)patients)who)were)readmitted))for)selected)highScost)or)highS
volume)conditions,)namely,)heart)attack,)
,)and)pneumonia.))

CONCLUSIONS)
A discharge educator providing patients with comprehensive
disease education that includes medication, diet, follow up
appointment necessity, and symptom recognition and extends postdischarge reduces re-admissions and improve quality of life as
perceived by the patient. While short-term follow-up demonstrated
improved knowledge, longer term follow-up of adherence patterns,
QOL, and re-admission rates is needed. ))

! The&patient&was&called&on&day&3,&14,&and&30&post&
discharge.&&The&AHCP&was&reviewed&and&patients&was&
assessed&for&any&possible&symptoms&and&directed&with&
appropriate&care.&

! Pre&and&Post&questionnaires&were&given&to&the&patient.&&
The&preNquestionnaire&was&given&prior&to&any&education&
while&the&participant&was&inpatient.&&Post&questionnaire&
was&given&on&day&30&post&discharge.&&These&
questionnaires&were&used&to&assess&&knowledge&of&
symptom&identication&and&&compliance&to&medication,&
diet,&weight&monitoring,&and&physician&followNup.&&The&
results&were&then&compared.&&&

10&out&of&the&10&participants&admitted&to&having&a&
discharge&appointment&at&time&of&discharge&and&9&out&
of&the&10&attended&that&appointment.&&&The&one&
participant&stated&it&was&other&on&the&questionnaire&
the&reason&why&they&didnt&attend.&&&

For&additional&information&please&contact:&
&
Sheri&Harrison&
School&of&Nursing&
Auburn&University&
SAHarison@tigermail.auburn.edu&
)