UCSF Medical Center is strongly committed to decreasing Heart Failure readmission rates. Heart Failure RN Discharge Coordinators are accessible seven days a week and have been instrumental in developing a heart failure readmission reduction program at UCSF together with strong participation from a large multidisciplinary team. Heart Failure readmission rates have decreased significantly at UCSF and the program’s successes have been recognized nationally.
Heart Failure readmission rates have decreased by implementing a number of best practices that include the Teach Back method of patient education, focused attention by discharge heart failure RNs, increased referrals to palliative care service, timely and appropriate follow-up care and stronger relationships with referral home care and skilled nursing facilities. Additionally, there has been an emphasis on increasing communication and collaboration with primary care physicians to ensure follow-up visits are scheduled appropriately.
Front-line Staff Lead the Way
Discharge teaching is an important component to reducing heart failure readmission. Patients must be educated on a number of important interventions, including monitoring daily weights, recognizing symptoms of fluid overload, taking medications appropriately, recognizing worsening symptoms and acting on them in an appropriate and timely manner. At UCSF, nurses utilize the Teach Back method which identifies gaps in learning and allows for reinforcement until understanding is verified. The Heart Failure RN Discharge Coordinators also call patients after discharge to make certain that they have retained the knowledge they learned while in the hospital, are following identified interventions, and have a follow-up appointment.
Utilizing Innovative Practices to Prevent Readmission
UCSF is initiating innovative practices, including aquapheresis, to ensure patients are in the most optimal state at discharge. This year the GeriTraCCC Program was also started which provides home visits for high-risk patients with heart failure by a UCSF doctor specializing in care of geriatric patients. This has been a very successful addition to the heart failure program as well as follow-up appointments with Nurse Practitioners in the Heart Failure clinic.
Data Transparency and Analysis
Heart Failure readmission rates are reported at the unit level as well as the organization-wide level. In addition, reports on heart failure core measures are displayed on the units. We are proud to report that our heart failure core measure discharge instructions are in the highest percentiles. We also monitor data on follow-up phone calls, MD appointments, and compliance with Teach Back methodology. We publicly share our heart failure readmission rates and are proud of our success!