From left, Eileen P. Williamson, RN, senior vice president and chief nurse executive, Nurse.com, meets with Mary Koch, RN, periop educator; and Mary Fuhro, RN, vice president, patient care services, at a recent Nurse.com roundtable.
Staff at Newark Beth Israel Medical Center, Barnabas Health, recognized the need to decrease the readmission rate for patients with heart failure in 2010. As a result of their efforts over the last two years, that rate has dropped from a high of 36.6% to 20.5%.
After identifying many reasons for readmissions, NBIMC applied for and received a grant from the Grotta Fund for Senior Care, a community advisory fund of the Jewish Community Foundation of MetroWest NJ.
“We chose to pursue Project RED because we found that it enabled us to engage and empower our patients and work as partners with them and our interdisciplinary team,” said Margo Malaspina, RN, BSN, director, quality management.
A hospital discharge process that is approved by the Agency for Healthcare Research and Quality, Project RED employs a designated nurse, which NBIMC calls a transitional care coach, who works with patients from the beginning of the hospitalization and reinforces the individualized plan of care using an easy-to-understand discharge manual.
“The program challenges us to think outside of the box, because the traditional method of discharge planning was not working effectively,” Malaspina said.
Through a series of questions, the take-home manual, called “Taking Care of Myself: A Guide for When I Leave the Hospital,” ensures that patients understand their medical condition and how to care of themselves, how to safely manage their medications and the need for exercise and proper nutrition. The pamphlet includes simplified medication charts with the names, dosing and scheduling of routine and PRN medications, and there is a separate sheet for follow-up appointment information, such as time, date, location, reason for visit and questions to ask at the appointment.
NBIMCs data on hospital readmissions showed the most likely days for readmission were between 13 to 15 days after discharge. “Based on that information, we now set up the patients first appointment before they leave the hospital and we make sure it is scheduled before the 13- to 15-day time period,” Malaspina said.
Patients also receive post-discharge phone calls from the nurse or a trained concierge who talks with them about their medications, medical condition and appointments within 48 to 72 hours after discharge. Then on days 10 and 15, NBIMC links patients with a home care agency as needed and follows up with patients who have returned to nursing homes.
After participating in the project, patients said it was the first time anyone asked detailed questions about their understanding and ability to care for themselves, reviewed medication administration in a simplified way and checked to see whether they could afford the medications. NBIMC has created a testimonial video that is shown to patients, physicians and members of the performance improvement council.
“We have applied for an extension of the grant in order to continue our work and expand it to the entire unit,” Malaspina said. “Our goal is to transform the way we prepare all patients for discharge to a proactive model beginning on day one of hospitalization.” Because of its success, staff also hope to replicate the project in the future with patients who have other diagnoses, such as pneumonia and chronic obstructive pulmonary disease.
Janice Petrella Lynch, RN, MSN, is a regional nurse executive.