We don't want to see heart failure readmission in our hospitals

August 10, 2016

Heart failure is the leading cause of hospital admission, illness and death in the United States. Nearly 5.7 million people are living with heart failure today and the American Heart Association expects that number to increase to nearly 8 million by 2030.

As a health care organization, we are working to connect care across different settings in order to improve heart failure patients’ quality of life, achieve better outcomes and deliver care in lower cost settings.

Rehabilitation in the skilled nursing setting

Providence Senior and Community Services created a heart failure program at Providence Mount St. Vincent, fondly known as The Mount, a skilled nursing facility in Seattle. The program is designed for heart failure patients who are discharged from the hospital but are not ready to go home yet.

Patients are admitted to The Mount’s transitional care unit for short-term physical and occupational therapy to help improve their strength, overall physical condition and help them reach their highest level of independence in daily activity. Patients also receive education on their condition and how to effectively manage their symptoms.

“Our goal is to stabilize these patients, return them home faster and get them home stronger and steadier so they are better able to manage their heart condition on their own,” explained Thomas Schaaf, M.D., chief medical officer, PSCS. “This in turn helps reduce hospital readmissions for this incredibly vulnerable and medically complex patient population.”

Home health clinicians provide ongoing education

Ongoing education is critical once heart failure patients return home, and that’s where our home health caregivers play an instrumental role.

The Providence home health ministries in Washington offer a heart failure program customized to meet patients’ needs. An interdisciplinary team works together to build each patient’s confidence, helping the patient reach personal goals and enjoy better quality of life.

The home health heart failure program is an example of how we are shifting from providing “health care” to supporting “health.” The program features home visits, patient education, medication management, nutritional counseling and rehabilitation.

The focus on education empowers patients to take better care of themselves.

“The further along the patient’s disease progresses, the worse their heart function gets and the more symptomatic they are,” Dr. Schaaf said. “Education helps the patients identify changes in their condition so they can alert their care team who can then adjust their medications or care plan. This type of early intervention can save the patient a trip to the hospital which makes sense both for the patient and the health care system.”

PSCS is working to establish consistent, reliable protocols and approaches to common diseases of the frail and elderly across all of its ministries. “That way wherever patients go they know they are going to get strong service and high quality care,” Dr. Schaaf said. “And, by having consistent processes we can do more effective quality improvement at our ministries as well.”