Re-engineered Discharge (RED) for Congestive Heart Failure Patients Courtney Nichols, RN, Rolling Plains Memorial Hospi

1. Re-engineered Discharge (RED) for Congestive Heart Failure PatientsCourtney Nichols, RN, Rolling Plains Memorial Hospital, Sweetwater, TX • Methods • -Through Case Managers / Discharge Advocates/ Direct Care Nurses: • -CHF patients are identified on admit • - DC teaching begins on admit / a survival kit is given to the patient. • - On DC med/rec is reviewed with the patient & a DC plan is provided. • - 48-72 hours post DC a f/u call is made by the DA. Then weekly for 4 weeks. • Results • The Discharge Advocate sees approx. 3-5 inpatients daily & calls 15-20 patients weekly. • CHF readmission rate prior to Project Red was 24.5%. • To date our readmission rate for CHF patients is 0%. • Conclusion • -Patient feedback has been positive, building a relationship is rewarding. • We work closely with our stakeholders: patients, physicians, local nursing homes and home health agencies. • Education of the disease process has decreased readmission rates & given the patient’s the confidence they need to manage their disease at home. Background - Readmissions are a hot topic in the last few years, reality is the patients are the ones that suffer the most. -RPMH offers a broad array of services: Improving the education process of CHF, arranging F/U phone calls, organizing all post DC services, confirm the medication plan, provide a written DC plan. -Our program was initiated on July 5, 2011 with a goal to reduce CHF 30 day readmission rate by 2% in 12 months. Objectives Focus on common reasons for readmissions. Educate the patient on their specific disease process Provide resources & support so the patient can manage their disease at home.