Reducing Hospital Admissions for Patients With Heart Failure by Implementing the Chronic Care Management Framework: A Cost, Quality, and Satisfaction Improvement Project
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Published:2022-05-16
Issue:2
Volume:15
Page:96-104
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ISSN:2380-9418
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Container-title:Journal of Doctoral Nursing Practice
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language:en
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Short-container-title:J Doct Nurs Pract
Author:
Koutlas Alexis,Jenkins Peggy
Abstract
ObjectiveTo reduce the rate of hospital admissions, and increase the perception of coordinated care for patients with heart failure and associated co-morbidities through improvement of interdisciplinary communication.BackgroundHeart failure patients with associated multi-morbidities and multiple provider visits are often left to navigate the health system independently. Limited provider to provider communication contributes to care fragmentation, unnecessary utilization and decreased satisfaction.MethodsA nurse-led complex care management improvement project imbedded care plans and formal and informal collaborative care conferences to improve interprofessional communication across the care continuum.ResultsHospital admissions decreased by 62% and length of stay decreased by 73% (n = 47, p < .001). Using paired t-test, satisfaction questions improved post intervention, and one was statistically significant (p < 0.05).ConclusionImproved communication strategies decreased hospital admissions and length of stay in one large Pacific Northwest health system. Days subject to readmission penalties decreased by 98% with a variance in pre-post charges of $615,000.Implication for NursesNurses and nurse leaders play a significant role in achieving the Triple Aim and can be instrumental in developing small multidisciplinary teams targeting improved coordination across settings and sectors.
Publisher
Springer Publishing Company
Subject
Health Policy,General Nursing
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