Reducing Readmissions for Patients with Heart Failure and COPD

While BMC’s all cause 30-day readmission rate was 10.96% in FY17, certain populations had much higher readmission rates particularly heart failure (HF) (23.73% FY17) and COPD (24.81% FY17).

With almost 1 in 5 HF and COPD patients readmitted, reducing readmissions for these patients has become an important hospital and quality priority.

Multidisciplinary pilots focusing on transitions of care started on 7/5/18 on E7N for patients with HF, with full go-live anticipated by February 2019.  Menino 6 is piloting similar strategies for patients with COPD.  Both pilots include:

  • Adoption of “Teach Back” methodology for all patient teaching
  • Partnering with home care providers such as our VNAs for home med reconciliation

Unique to HF:

  • HF consult triggers for patients on non-cardiology teams
  • Standardization of patient instructions in AVS using smart phases for HF
  • Facilitated early discharge transitions of care (TCM) appointments
  • Personalized reminder calls by Cardiology Clinic staff one day before post discharge appointments for patients with HF

Unique to COPD:

  • Inpatient COPD NP consult with follow up outpatient appointment. Welcome Alexis Gallardo Foreman, NP to the COPD care team!  Alexis is available to see patients with COPD in both the inpatient and ambulatory settings.

During the 8-week HF pilot on E7N, the 30d readmission rate decreased from 21.6% to 12.9%., with most reduction seen in the 7-10d readmission rate.  In Jan-Nov 2018, COPD readmission rate was 20.7%.

You are the critical link to connecting our patients with HF and COPD to these proven strategies for reducing readmission and improving health.  Please consult the HF or the COPD service to activate patient care resources!