Implementation of an integrated plan of care decreased heart failure readmission rates by 36.9%, with patients lacking the discharge teaching/packet being almost 7 times more likely to be readmitted.
Does an integrated plan of care with redesigned inpatient education decrease heart failure readmissions in a rural community?
A tailored integrated plan of care focusing on inpatient education and early follow-up significantly reduced heart failure readmissions in a rural community.
Effect estimate: OR ~7
PURPOSE: The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model. METHODS: An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge. RESULTS: Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted. IMPLICATIONS: The IPC was effective in decreasing HF readmissions. CONCLUSIONS: These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF.
Vesterlund et al. (Wed,) conducted a other in Heart failure. Integrated plan of care (ICP) including education, discharge packet, nutrition, case management, appointments, and follow-up call vs. No discharge teaching/packet was evaluated on Heart failure readmissions (OR ~7). Implementation of an integrated plan of care decreased heart failure readmission rates by 36.9%, with patients lacking the discharge teaching/packet being almost 7 times more likely to be readmitted.
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