DECREASING HEART

FAILURE READMISSIONS
BY EDUCATING HEALTH
CARE PROVIDERS
Student
South University
  Current rehospitalization rates in hospitals have identified several
chronic health conditions that are high risk for an increased return
to hospital rates within 30 days of discharge.
 Conditions include chronic obstructive pulmonary disease
(COPD), end-stage liver disease (ESLD), end-stage renal disease
(ESRD), diabetes mellitus, and heart failure.

PROBLEM 


High-risk conditions are increasingly more prevalent in
rehospitalizations.
The Medicare and Medicaid guidelines, as dictated on the CMS

STATEMENT
site, outlines the benchmarks of the standards of care.
 The local physician's group and the rehabilitation center are
working in collaboration to decrease the rate of rehospitalizations.
 This initiative to decrease unnecessary rehospitalization involves
providing education and implementing tools to ensure that
evidence-based protocols (EBP), and compliance rates remain
high in the delivery of care.
  Using the Heart Failure clinical tool will help decrease return to hospital
occurrences and provide a better patient outcome in the long run.
 The transitional patient usually has a complex medical history that places
them at risk for rehospitalization within 30 days.
 The BOOST protocol worksheet will help providers to determine if a patient

PROBLEM
is at high risk for rehospitalization once transitioned back to the home
environment.
 HRRP defined rehospitalization as occurring within 30 days of discharge
from the same or another hospital with the same condition or complication of

STATEMENT
initial hospitalization.
 The medical conditions that the HRRP defined as high risk for readmissions
included heart failure, COPD, AMI, and pneumonia.
 An established methodology created to calculate the excess readmission ratio
for each applicable condition, which uses a risk adjustment methodology
endorsed by the National Quality Forum (NQF).-Summarize background and
significance including a general statement of problem
  The need for health care providers to identify high-risk heart failure patients
has become imperative in medical and nursing practice.
 (P) High-risk CHF patients are returning to the hospital unnecessarily.
 (I) Health care providers intervene by implementing a protocol to determine
the risk of rehospitalization.
 (C) The administration presently has an admission team that pre-screens
pending admissions and determines if the facility can manage the case or not.
An admission nurse then assesses the patient and hospital discharge orders for

PICOT
any discrepancies in assessments and documentation. Within 72 hours, an MD
must evaluate the patient fully with a comprehensive chart review. Afterward,
the nurse practitioner does weekly follow-ups until discharge home or transfer
to long term care.
 (O) The facility leadership and DNP student convened a team of providers
and nursing staff to develop an evidence-based protocol based on the Better
Outcomes for Older adults through Safe Transitions (BOOST) guidelines in
the management of patients with heart failure.
 (t) The expected time for the development and implementation of the BOOST
protocol and Heart failure tool will take approximately 6-8 weeks.
  Keywords and search phrases used for the exhaustive search
process included hospital readmission, chronic illness

LITERATURE
admissions, post-acute readmission, Medicaid and Medicare
guidelines, COPD, CHF, diabetes, hypertension, and obesity.

 The HRRP guidelines mandate that hospitals and primary

REVIEW: HIGH 
care providers have to follow up with specific high-risk
health populations.
In response to the growing health care crisis of high

RISK HEALTH
readmissions due to chronic conditions, the Centers for
Medicare & Medicaid Services (CMS) created the Hospital
Readmissions Reduction Program, which monitors hospital
readmissions rates.

POPULATIONS The national benchmark readmission rate is 3% per year.



 Hospital re-admission reduction is a primary focus of health

care systems worldwide
  Evidence on the prevention of unplanned hospital

LITERATURE
readmissions increasingly points to the importance
of early in-hospital and post-discharge rehab
interventions aimed at addressing patients’ needs
as early as possible.

REVIEW:  The common themes throughout the literature

review have been centered around the fact the
often patients are being discharged from the
HOSPITAL hospital prematurely and without sufficient
support or preparation.
Researchers have noted that the trend of
READMISSION

rehospitalizations occurs within 30 days of
discharge from the hospital.

REDUCTION
 Post-discharge care starts with support in the
community health care settings.
 LITERATURE
 According to the article published by American Nurse Today
in 2015, it was estimated that approximately 20% of
Medicare patients were readmitted after 30 days.
 The researchers in this article found that there was a failure

REVIEW: to have adequate discharge planning, patient and caregiver

education, full communication with the PCP, and appropriate
community support for disease management.

PREVALENCE
 In recognizing the high-risk chronic diseases, several
interventions were used to determine readiness for discharge
and the level of care needed to support the patient and
caregivers.

OF Researchers found that rehospitalizations occurring within


seven days are more under the hospital’s control and more
preventable than later ones. Higher-risk patients remaining in
the hospital longer had a lower readmission rate once

READMISSION
discharged to subacute care facilities.
  This academic literature review on decreasing
readmissions in high-risk patient populations with
acute, chronic co-morbidities; will explore the
extensive studies that have been conducted in the
United States about the Medicare/Medicaid

CSP 
guidelines.
This quality improvement project will require the
use of quantitative variables that will include

OBJECTIVE 
independent variables, dependent variables,
sample variables, and extraneous variables.
This project aims to develop and implement an
ongoing, organization-wide strategy to prevent
hospital readmissions.
  The framework is the created heart failure tool and
the Project BOOST model. Project BOOST,
defined as (Better Outcomes for Older adults
through Safe Transitions), is a comprehensive
program that aims to reduce hospital readmissions
significantly.

THEORETICAL  Project BOOST was created in 2009 by the

Society of Hospital Medicine (SHM), through a
1.4 million grant from The John A. Hartford

FRAMEWORK
Foundation.
 The BOOST protocol uses the 8P scale to help
providers and caregivers easily identify high-risk
readmission patients.
 Theories developed at this level have a more direct
effect on nursing practice.
  In applying the nursing process theory towards the
PICOT question in decreasing the readmission rate
for CHF failure, a change theory also has to be
employed to make the heart failure tool and
BOOST protocol successful with improved patient

THEORETICAL 
outcomes.
This quality improvement project will require the
use of quantitative variables that will include

FRAMEWORK 
independent variables, dependent variables,
sample variables, and extraneous variables.
Extraneous variables must be controlled for this
project to prevent false positives of the null
hypnosis and distort the data collected.
  With healthcare costs continually rising and
hospital reimbursement dependent on patient
satisfaction, length of stay, and return to
hospital rates, hospital readmissions have
become a manner of measuring the quality of
patient care.
 Mortality rates increase with
METHODOLOGY rehospitalizations of the chronically ill as a
whole.
 This places health care facilities, primary
care providers, and nursing at the forefront of
reducing hospital readmissions and
improving patient outcomes.
  This design is based on quality improvement (QI)
measures to improve patient outcomes.
 The goal is to educate health care providers in a 28-
day clinical pathway, ineffective heart failure
management in order to improve overall patient care
and outcomes.
 This quality improvement study will take place at the

METHODOLOGY local skilled nursing facilities that Access Health Care

Physicians has admitted patients from the local
hospital.
 Each skilled nursing center has a whole sub-acute
unit with long term care units. The focus of this QI
project is to improve the care of heart failure patients
on the sub-acute units to prevent hospital
readmissions.
  The Heart Failure tool allows for medical providers and nursing to follow
specific clinical pathways for effective heart failure management.
 Additionally, the collaborative health care team can improve patient outcomes
for transition home by incorporating the BOOST protocol. Both models will
have interventions implanted to prevent the rehospitalization of the heart
failure patient.
 These models of care will be used to quantitative measure the use of the heart
failure tool with the transition of care. The providers and nurses will have the
forms available in 3-day intervals as the journey of care for the heart failure

METHODOLOGY
patient is followed for 28 days.
 The heart failure QI project consists of two major sequential processes that
involve planning and implementation of the BOOST protocol and the Heart
failure tool. The planning process consists of institutional self-assessment,
team development, enlistment of stakeholder support, and process mapping.

 This approach is intended to prioritize the list of evidence-based tools in

BOOST and the Heart Failure Tool. The use of these tools would best address
individual, institutional, medical, and nursing contexts related to the care
of high-risk patients’ heart failure patients.
  Project BOOST may be a viable QI
approach to achieve a decrease in hospital
readmission goals.
 This tool was initially used for evaluation
of participation in Project BOOST by 11

FINDINGS hospitals of varying sizes across the

United States.
 Project BOOST has shown an associated
reduction in rehospitalization rates (free 5
2.0%, and relative 5 13.6%, P 5 0.054).
  However, the patient's length of stay after
readmission did not change after hospital
readmission.

 Anticipated findings should be an overall

decrease of return to hospital rates, once the
FINDINGS patient is discharged or appropriately placed
in long term care or assisted the living.
 Overall the QI project should give a clear
indication that rehospitalization can be
delayed or avoided with a full health care
providers and nursing intervention and
education.
  The collaborative partnership from the
study site, health care providers and
nursing would require consistent
mentorship and guidance to providers and
nurses to focus on prevention of hospital
readmissions for CHF patients intensively.
FINDINGS  Another limitation may stem from upper-
level management to share analytical data
about financial loss and gain related to
decreasing rehospitalization within the six-
week study time frame.
  The implications of this project are two-
fold:
 The expansion of knowledge regarding the
incidence of heart failure risk factors.
 Interventions needed to anticipate and
prevent 30-day hospital readmissions.
IMPLICATIONS  Costs and resources continue to be a
driving force behind hospital and rehab
facility initiatives in innovation and
ongoing improvement in care delivery.
  The nurse leader and medical provider should apply this
knowledge to recommend changes to the current practice
reducing risk for readmissions and applying the HF
screening tool.
 The Affordable Care Act requires CMS to reduce payments
to hospitals with excess readmission rates compared to the
national average in 2014, starting with a 1% reduction and

IMPLICATIONS 
increasing to a 3% reduction in Medicare payments by 2016.
The medical model and nursing discipline have an
obligation to participate in strategies that impact
reimbursement around the 30-day readmissions.
 This particular project demonstrates the value of change and
innovation that directly impact the quality of patient care
across the continuum.
  Limitations in the study of reducing hospital
readmissions by using the Heart failure tool and
BOOST protocol may lie in provider buy and
compliance in addressing potential problems of
declining health early and providing preventative care
measures.
 The first limitations are that only one sample
population was used; medical providers were caring

LIMITATIONS 
for HF patients within the medical group.
The second limitation involved the data collection in
the medical record.
 Other limitations that may be demonstrated may be in
continued collaboration in facility data collection
related to the BOOST protocol and heart failure tool.
  -           Describe the cost to keep the
practice change going

SUSTAINABILIT  -           Describe the plan/s to keep the

practice change going (or not)

Y  -           Include all needed stakeholder

buy-in
 PLANS FOR
DISSEMINATIO
N
APPLICATION
TO DNP DNP Essentials (highlight 3 or 4 essentials

maximum as the most applicable)

ESSENTIALS
 I would like to extend a heartfelt thank you to
my academic advisor, Dr. George Perez
Smith, DNP, APRN, who supported my
acceptance into the program, persevered with
me over the last five years and calmed my
ACKNOWLEDGEMENT fears many times over. Finally, I thank my
mentors that helped to grow more into my
S role as a Doctor of Nursing Practice. This
program was one of the most formative
experiences of my life, and I have valued
every minute of collaboration and learning
with faculty and fellow students in my
cohort.
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Feather, A. (2018). Managing Patients with Multimorbidity. Medicine, 397-401.

Goldberg, R. J. (2016). Identifying High-Risk Patients to Reduce Thirty-Day Readmissions to

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REFERENCE
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 New Courtland Center for Transitions and Health. (2020, January 9). Transitional Care Model.

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THANK YOU
AND
QUESTIONS