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6th World Nursing and Healthcare Conference

London, UK

Jennifer Kitchens

Jennifer Kitchens

Eskenazi Health, USA

Title: Interdisciplinary collaboration to reduce heart failure readmission rates and improve care transitions


Biography: Jennifer Kitchens


Background: Heart failure (HF) readmissions can lead to poor patient outcomes, escalated healthcare costs, and are indicative of inadequate management or gaps in care. The average cost of a HF readmission is $13,000. Interdisciplinary collaboration to improve care transitions is one way to reduce HF readmissions. Purpose: The purpose was to improve heart failure care transitions and reduce hospital readmissions of patients diagnosed with HF within 30 days of discharge through a citywide interdisciplinary collaboration. Methods: A citywide coalition for patient safety workgroup that included multidisciplinary representatives from hospitals, skilled nursing facilities (SNF) and home health care agencies (HHCA) collaborated to reduce heart failure readmission rates through a four-phased community-wide effort. Phase 1: Improving preventable HF readmissions by better medication management; early follow-up care; symptom management; post-discharge care management. Phase 2: Implementing minimum care standards for treatment of patients with HF in SNF. Phase 3: Improving verbal handoff communications for patients transferred from hospitals to SNFs. Phase 4: Implementing minimum care standards for treatment of patients with HF in HHC. Results: HF readmission rates for HF (including all patients city-wide, not just Medicare) was 7.37% in 2010 compared to a post-program rate of 4.92% in 2014. HF readmission rates for any reason (including all patients city-wide, not just Medicare) was 16.75% in 2010 compared to post-program rate of 13.93% in 2014. Feedback to the workgroup from the community partners demonstrated satisfaction with the program. Conclusions: City-wide interdisciplinary collaboration among representatives of hospitals, SNF and HHC led to reduction in readmissions for patients with HF.