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Care Coordination Program for
Heart Failure
Susan Levine RNDirector Clinical Resource Management
Carolyn Timmons BSN,RN Lead Clinical Care Coordinator
Memorial Hospital Pembroke is a full-service, fully accredited hospital. From emergency, medical and surgical care to innovative
outpatient services, home health and educational programs, patients benefit from a full continuum of care.
“When you come to a fork in the road…. Take it”
Goal
Decrease the Heart Failure 30 day readmission rate and associated costs. Improve patient outcomes by providing disease specific education and safe transition of care from hospital to next level of care.
The Road Led Us To…
Executive level approval
Identify Clinical Department Leader
Identify Lead Clinical Care Coordinator
Identify multidisciplinary team
Identify Physician Champion
Create educational material
The Road Led Us To…
Set implementation date for inpatient program
• Coordinate with Nursing Educate all staff Train Clinical Care Coordinator on database Introduce program to Physicians
• Letter
• Physician dining room slide show
• Poster board
• Face to face presentation
Program Criteria
Patient Baseline interview
Self assessment
Identify personal goals
Initiate Personal Health Record (PHR) with patient
Chart Information
Baseline Interview
Educate
Education is empowerment
Provide one on one inpatient and
group classes
Transition community education
Coordinate care
Hospital Visits
Advocate Include Patient Family Centered Care
Coordinate insurance
Schedule Physician appointments
Schedule outpatient testing / procedures
Communicate Discharge plan
Personal Health Record (PHR)
Instruct on follow-up appointments / procedures
Post discharge telephonic communication
Personal Health Record (PHR)
Alerts
Phone Calls
The Road So Far….
Implemented the Care Coordination Program for Heart Failure January 2010.
Enrolled 127 patients into program Jan-May 2010
250 hours of one to one education 60 interdisciplinary inpatient education classes 45 hours post hospitalization telephonic
follow-up
Decreased the 30 day re-admission rate from 1st Qtr 2008 to 1st Qtr 2010 by 63%
Quarterly Heart Failure Readmission Rate
0
2
4
6
8
10
12
14
1st Qtr
MHP 2008 MHP 2009 MHP 2010
12.9% 9.1% 4.8%
(MHP to MHS)
The Road Leads To…
Reduced readmissions
Improved quality of care
Improved quality of life
PATIENT FIRST
Provide the Right Care, at the Right Time, for the Right Reason
QUESTIONS ?
Contact Information
Susan Levine RN
Director of Clinical Resource Management
Carolyn Timmons BSN, RN
Clinical Care Coordinator
