Nurse Direct - follow-up for CHF patients

Monday, June 29, 2009 at 12:13:05 PM

We at United Health Services Hospitals are actively working to improve the way we care for patients who are admitted with congestive heart failure or diagnosed with the condition during their hospital stay. Our goals are to improve the patient's quality of life, ensure that they receive first-rate follow-up care after they are discharged and prevent re-admission to the hospital within 30 days of their release. It's all part of our overall commitment to the Lean Six Sigma enhancement of patient-centered care. To achieve our goals, United Health Services Hospitals will be working with Stay Healthy and its NurseDirect service, as well as with Twin Tier Home Health's Heart at Home, to follow up with CHF patients after their discharge. NurseDirect will be providing disease management, and will be taking referrals starting July 6.

Case Managers can refer your patients through the ECIN System and a NurseDirect nurse will follow up. Nurses and Providers please feel free to speak to the case managers to ensure the referral was made during the patientís hospitalization. Providers as you are seeing patients in the office if you feel they will benefit from the disease management please call or have one of your office staff make the referral to Stay Healthy. In the meantime, if you have questions regarding how this new disease management program works, contact Sara Delafield, Manager of Stay Healthy, at 763-6722.

Here is a summary of the program:

Every patient who is identified as a Congestive Heart Failure Core Measure patient should be referred. The program will include follow-up telephone calls by a registered nurse at specific intervals after the patient goes home. The first call will start within a couple days of discharge. Information regarding the various topics discussed by the nurse and the patient over the phone will be mailed to the patientís home. Patients will be offered the chance to participate in classes at Stay Healthy. The classes will be provided by a registered nurse and a registered dietitian. They will teach patients how to stay healthy through diet, medication management and lifestyle changes as ordered by the patientís physician.

Patients will be encouraged to call NurseDirect with any questions they may have regarding their health or treatment. Depending on the nature of the questions and the information gathered, NurseDirect may then make a referral to the patientís physician. The program engages the patient and their health care provider to monitor and control the symptoms of this particular heart condition, thereby keeping the patient healthier and out of the hospital. A main goal of the program is to encourage compliance with treatment. Through established relationships, the staff at NurseDirect will communicate with providers to set appointments and encourage the most appropriate level of care for the patient.

In addition to the NurseDirect aspect of the program, Twin Tier Home Health will continue to offer its Heart at Home service to patients with CHF. If you have patients who are eligible for home care services, please continue to refer them to this program (if your CHF patient is not driving on a regular basis, they qualify under Medicare and private insurance for Heart at Home). If you are making a referral to both the NurseDirect and the Heart at Home programs, make a note in the ECIN referral to NurseDirect. This will facilitate communication between Twin Tier and NurseDirect to ensure a better patient experience.

New Medicare rules will curtail reimbursement to hospitals for CHF patients readmitted within 30 days of discharge, so addressing this issue is a very high priority at Wilson Medical Center and Binghamton General Hospital. Improvement of care for the CHF patient is the first major project of the Lean Six Sigma endeavor, and the CHF team has invested a great deal of time, energy and innovative thinking into discovering the causes of preventable readmissions and limiting them to the greatest extent possible. Your diligence in referring your patients for NurseDirect follow-up, Heart at Home or both services will help ensure the continued success of this CHF initiative.

If you have any questions regarding the CHF Lean/Six Sigma team and/or CHF Core Measure requirements and processes please contact Emily Dorval, Nurse Manager South Tower 3, at 763-6062.


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