Heart Failure (HF) Readmissions
According to the American Heart Association, 5.7 million Americans are living with heart failure. An additional 670,000 new cases are diagnosed annually, up from 500,000 a few years ago. With the aging of the population, Heart Failure is poised to reach epidemic proportions in coming years. Heart Failure readmissions (taking patient away from home) remain a continuous challenge in the care of the Heart Failure patient. Although gains have been made over the past five years, still more than 20% of patients are readmitted within 30 days.
One of Lexington Medical Center’s goals is preparing our HF patients for a safe transition home with the desired outcome of preventing the need for readmission. Some strategies to meet this goal are: providing a dedicated Social Worker to work with HF patients and family members, increasing referrals to Home Health Services, providing digital scales to patients on admission for use while hospitalized and to take home for easy daily weight monitoring, scheduling early follow-up appointments, follow-up phone calls within 72 hours of discharge, and identifying and connecting patients with a primary care physician. Lexington Medical Center has received a grant from the Lexington Medical Center Foundation for four consecutive years to purchase digital scales for our HF patients who do not own a scale.
Since 2014, Lexington Medical Center has received an annual grant from our Lexington Medical Center Foundation to provide 20 hours of non-medical in-home assistance to individuals with a known diagnosis of heart failure and other chronic diagnoses who are at high risk for readmission for up to 30 days after discharge from an acute care hospital stay. Starting in July 2017, this program was funded by the Duke Endowment and will be continued through June 2020. Lexington Medical Center has contracted with a non-medical home care agency to provide this transitional support. Patients must meet all eligibility requirements to qualify for this service. This program is used in conjunction with all other discharge planning activities that are applicable to the individual patient’s needs, including home health services, durable medical equipment, pharmaceutical assistance programs, and referral to other community programs.
In the spring of 2019, a Patient Care Navigator position was created specifically to help patients with heart failure navigate their transition from hospital to home. The Patient Care Navigator calls high risk patients between 24-72 hours after discharge. During this phone call, the Patient Care Navigator reviews the patient’s plan of care and medication list, addresses any symptoms the patient may be having as well as ensures the patient received any equipment or other in-home assistance that was ordered at discharge. Additionally, the Patient Care Navigator is responsible for scheduling all follow up appointments that were ordered at discharge. National guidelines from the American Heart Association state that patients should see their Primary Care Physician or their Cardiologist within seven days of discharge and LMC’s Patient Care Navigator is helping to make sure that happens. Overall, the Patient Care Navigator serves as a central hub for patients with heart failure so when they leave the hospital, they know who to call if they need help.