1. UTILIZING CARE MANAGEMENT NURSES TO IMPROVE TRANSITIONS IN CARE
IN THE OUTPATIENT SETTING FOR HIGH RISK CHF PATIENTS
TANISHA R. DAVIS, BSN, RN, CCRN
UNIVERSITY OF PITTSBURGH/ UPMC HEALTH PLAN
PITTSBURGH, PA
Background: Approximately 5 million Americans have been diagnosed with Heart Failure (HF)
and the number is steadily climbing, as over 500,000 new cases are diagnosed annually. HF
remains the number one hospital readmission diagnosis for Centers for Medicare and Medicaid
Service (CMS). With the passage of the Affordable Care Act and decreased reimbursements for
patients admitted within 30 days of discharge, it is imperative that healthcare facilities implement
quality improvement initiatives to decrease the number of HF admissions, especially from skilled
nursing facilities. Improving the safety during transitions in care from the hospital setting to
skilled nursing facility to home care has become a highly researched area for quality
improvement. Utilizing all aspects of the multidisciplinary team to improve the patient’s safety
and ensure the patient is informed on current disease processes; helps improve care coordination,
promote patient engagement and improve patient outcomes.
Methods: Utilizing a Plan, Do, Study, Act (PDSA) framework, a work flow analysis was
performed and analyzed to assess transitions in care for a large, metropolitan hospital system’s
health plan members in Western PA. The assessment and discharge processes are standardized
within the health plans electronic health record system. In the pilot study, all HF patients in the
13 skilled nursing facilities that admit health plan members will have the following: (1) a risk for
readmission assessment, (2) disease specific patient education via the teach back method and (3)
multiple medication reconciliation assessments at key care transitions points. An education
session with case managers of the health plan responsible for care coordination from the 13
skilled nursing facilities to the patient’s home was implemented. The CNLwill work with the
case managers of the health plan to coordinate care transitions during weekly follow up sessions.
Outcomes: The project is ongoing. Pilot data will be available Summer 2016. Data reflecting
pre, post staff education will be collected and analyzed. HF DRG data regarding readmission
rates will be collected and analyzed. Staff compliance through direct observation and chart
review will be collected and analyzed.
Recommendations: Risk assessment, patient education and multiple medication reconciliation
along the continuum of care between skilled nursing facility and home are essential. Addressing
current recommendations for comprehensive, disease specific patient education in the outpatient
healthcare settings helps improve outcomes by engaging the patient in their own disease process
and helps them make informed decisions about their care. Utilizing a teach-back method to
provide patient education promotes patient retention of information. Utilizing a
multidisciplinary health team focus to address patient medication reconciliations during multiple
transitions in care promotes patient safety all at levels of care.