This post was authored by Marie Boyle Reinman, RN, director of heart and vascular services and critical care nursing at Beaumont Hospital in Grosse Pointe, MI; and Sarine John-Rosman, MD, FACC.

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.

Beaumont Grosse Pointe is a 280 bed community hospital and it was felt we might have an easier time getting our arms around the HF readmission issue due to our size.  We chose the metrics we thought would have the biggest impact:

1. Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within seven days after discharge
2. Providing the patient with documentation of the scheduled appointment
3. Working to ensure that the patient arrives at the appointment within seven days of discharge

We had buy-in from our cardiology practices regarding accommodating appointments in the offices within seven days, which was a huge benefit to us.  Additionally, the Administration supported our efforts and worked with our health system’s Home Care division to position a nurse in the hospital with experience in HF to assist in our efforts.  She scheduled the appointments and made follow-up calls to the patients.  She also compiled a list of transportation resources for these patients due to their challenges getting to appointments and did a great deal of one-on-one teaching with this patient population.

We already had a robust HF calendar for patient teaching purposes, but our challenge in the beginning was identifying HF patients in-house, as admissions from the EC are frequently listed as “shortness of breath,” or “lower extremity swelling,” or something of that nature with no mention of HF until they are coded on the back end.  Also, there are patient lists generated from the electronic medical record (EMR) as well as from the Care Management documentation system, but no one real “source of truth.”  As such, the system recognized the issue and all three hospitals along with IT Informatics are working on building a HF patient list that queries the system for things like SOB or swelling as an admitting diagnosis, pharmacy order for loop diuretics, and others cues.  However, the process has had its challenges, including no easy way to mine discreet data fields such as the ejection fraction on an echo report (due to the fact that the echo report is linked in the EMR from a different template platform).  We continue to work on this project.

Another challenge was having reliable contact information from the patient and caregivers so discharge contact could be made to verify appointments were kept.  Finally, due to resource allocation, it was a challenge following patients who were discharged over the weekend.

We have seen some success in terms of decreased readmission rates for HF and are cautiously optimistic.  We will continue to refine the work we do and hopefully offer any best practices we have developed to other chronic disease integration teams across our hospital and system.

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

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