St. Luke’s Hospital: Where Patients’ Home Care Needs Are Anticipated at Discharge

This story originally appeared in IHI's 2008 Annual Progress Report.
For some patients, being discharged from the hospital is a mixed blessing. It can feel both great and scary to return home, especially for those who need to take on new and potentially confusing responsibilities for self-care.
At St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, a program called Transitions Home is addressing these concerns for patients with heart failure. By providing self-management support for patients at home, the hospital is reducing its rate of readmissions for heart failure patients.
The program includes a combination of patient-friendly written information along with a home visit from a nurse, a physician office visit, and follow-up telephone calls. There are also weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support. 
The written materials are short and clear. “We really looked at how to succinctly get across the information we want patients to know,” says Peg Bradke, RN, MA, Director of Heart Care Services at St. Luke’s. Using feedback from focus groups, the team designed simple information packets using a “green-yellow-red zone” graphic showing patients how to interpret daily symptoms. 
In all stages of the program, staff use a technique called “Teach Back” to gauge patient understanding. “We use it in the hospital, at the home visit, and in follow-up phone calls,” says Bradke. “We ask them the same set of questions about symptoms, diet, and medication.  In the home visit and phone calls, we get complete responses more than  80 percent of the time.”
Percent of Patients Satisfied with Discharge Instructions


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