The MedProvider Inpatient Care Unit – Congestive Heart Failure Project
Baylor University Medical Center
Dallas, Texas, USA
Team
Rainer Khetan, MD
David Ballard, MD, PhD, FACP
Mae Centeno, MS, RN, CCRN, CCNS, APRN, BC
Dennis Daly
Shelley Hall, MD
Ruth Ann Kauffman, RN, CCTC
Billy Moore
Gail McVea, RN, MS
Randlow Smith, MD
Barbara Spreadbury, RHIA, MBA
Aim
Decrease the overall 30-day readmission rate for congestive heart failure (CHF) patients by 25 percent within 6 months.
Measures
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Compliance with administration of discharge medications within 24 hours after discharge
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Discharge literature read and understood by patient and/or family/caregiver
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Attended follow-up appointment with Heart Failure Clinic
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Appropriate follow-up with a cardiologist
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Two week follow-up visit with a primary care physician (PCP)
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Readmission within 30 days after inpatient discharge
Changes
Our process analysis allowed us to identify communications and scheduling problems that resulted in outpatient management failures for CHF patients. By modifying those processes and improving and validating communication, we were able to decrease readmissions.
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Redesigned the discharge process to:
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Emphasize patient education and responsibilities
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Assure that follow-up appointments are attended
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Assure that patient understands his/her responsibilities
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Maximize patient satisfaction
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Prescriptions were written and home medications dispensed prior to discharge
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Patient literature was provided and then a follow-up call was placed to determine if patient read and understood the material and to answer questions
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Appointment made with the Heart Failure Program for follow-up
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Patient follow-up improved through RN initiated call within 24 hours after discharge to determine medication and home care instructions compliance
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Improved communication between hospitalists, PCP, cardiologist and Heart Failure Clinic to clarify roles and responsibilities and to minimize duplicative actions
Results
    
Summary of Results / Lessons Learned / Next Steps
Preliminary results suggest the following:
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Information flow has been simplified and resulted in a decrease in failures related to process errors
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Patients receive more valuable resource information than before and knowledge is shared and confirmed between caregiver and patient
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Customers (patients and primary care physicians) appreciate the improved communication and close follow-up
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Patient compliance and understanding of their disease management has improved
Contact Information
Rainer Khetan, MD
RainerK@baylorhealth.edu
[Storyboard presentation at IHI's National Forum, December 2004]
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