This post was authored by Jacqueline Jones, MSN, APN-BC, CEN-CEN, manager of NP/PA cardiovascular services at Crittenton Hospital Medical Center; Jill Klaver, JD, RHIA, medical staff quality specialist at Crittenton Hospital Medical Center; and Samer Kazziha, MD, FACC, executive medical director, cardiovascular program at Crittenton Hospital Medical Center.

With heart failure (HF) readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with Michigan’s  Quality Improvement Organization, MPRO, and the Great Detroit Area Health Council to form the  Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.” This post is part of a series on H2H at the local level.

At Crittenton, we have worked on reducing readmissions since 2009.  The “See You in 7” Collaborative was a welcomed opportunity to share ideas with others, specifically in the context of HF. We have a strong HF program, and have assembled a great team of professionals committed to improving our outcomes.  Preventing unnecessary readmissions is a key component of improving outcomes, as well as improving our patients’ quality of life.

The collaborative gave us the framework and the freedom to work on the issues we felt would be most beneficial for us.  We focused on the following:

• Identify and address barriers to keeping follow-up appointments for all HF patients
• Ensure all HF patients arrive at their appointments within seven days of discharge
• Make the discharge summary available to follow-up care providers of all HF patients

We focused on processes that patients face in keeping their post-discharge appointments.  Data was gathered from the medical record and from interviews with HF patients and their caregivers.   Primary care physicians and cardiologists were surveyed to determine whether their practice schedules could accommodate appointments within a week of discharge.  We then surveyed physicians to discover if they typically have a discharge summary or other pertinent clinical information at that first office visit post-discharge.

We discovered that many HF patients have transportation difficulties.  This led to the publication of a comprehensive transportation guide now used for all patients throughout our facility.  The time frame for discharge summary completion was shortened so the summary can reach the post-discharge care provider more quickly.  In addition, we discovered that a discharge process we had developed in 2009 for appointment setting prior to discharge wasn’t working well, so we made some process changes and continue to improve in this area today.

One of the most important lessons we learned as participants in the collaborative is that once a process is put into motion to address a problem, we can’t simply assume that the process continues to work flawlessly.  We now re-check process compliance to ensure continuous decline in readmissions for HF.

Stay tuned for other perspectives from the Southeast Michigan “See You in 7” Hospital Collaborative.

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