NCDR.17 Research Explores Success of ACC’s Patient Navigator Program

New research exploring heart failure (HF) education processes, post-discharge phone calls, scheduled follow-up appointments and readmission rates were presented as poster abstracts during NCDR.17 in National Harbor, MD.

Standardizing HF Education and Documentation

Results from a study led by Marit S. Planton, BSN, et al., at St. Vincent’s Medical Center (SVMC) in Bridgeport, CT, found that the ACC Patient Navigator Program helped to successfully identify opportunities for improvement in the HF education process, reduce readmission rates, improve patients’ understanding of HF and encourage compliance among staff.

Over the course of 11 months – from January to November 2016 – SVMC saw its HF education documentation process improve by 112.5 percent, from 32 percent to 68 percent. SVMC plans to expand the new education process to all inpatient hospital units in order to include HF patients who may be in non-cardiac units.

Establishing the P.U.M.P Club

Successful HF readmission reduction at Saint Mary’s Hospital in Waterbury, CT, demonstrated the effect working across institutional silos has on patient outcomes. A study led by Paul Kelly, MD, FACC, et al., found that both short-term and long-term readmission rates declined after establishing its “P.U.M.P Club.”

By creating a multidisciplinary team, holding standardized weekly meetings to review all HF patients and using cardiovascular rehab and pet therapy with patients, the total number of patients readmitted within 150 days of hospital discharge declined from 48 to 31. Moving forward, Saint Mary’s Hospital aims to expand the program and standardize methods across its five-hospital regional health system.

Reducing Hospital Readmissions For AMI and HF Patients

According to a study led by Camille Randol, RN; Jamal M. Brewster, RN; and Richard E. Shaw, PhD, FACC, ACC’s Patient Navigator Program and ACC’s ACTION Registry-GWTG contributed to the reduction of 30-day readmission rates in acute myocardial infarction (AMI) and HF patients between 2014 and 2016.

The 30-day readmission rates for AMI patients at the California Pacific Medical Center in San Francisco, CA, dropped from 12 percent to 8.7 percent, while rates for HF patients dropped by 1.5 percent total. Other results include a 39 percent increase in 7-day follow-up and 82 percent increase in nursing teach back.

Expanding Post-Discharge Phone Calls

Resources from ACC’s Patient Navigator Program helped the University of Utah Hospital and Clinics (UUHC) successfully achieve its goal of improving the number of post-discharge phone calls made, according to a study led by Dawn Young, et al.

Through the program, UUHC monitored its progress and made adjustments to its processes over the course of a year. The number of phone calls made within 48 hours increased by 57.1 percent, from less than 5 percent in January 2016 to an average of 61 percent by December 2016.

Eliminating Barriers to Follow-Up Appointments

Scheduled 7-day follow-up appointments are important for HF patients, but they do not guarantee attendance, according to a study led by Lisa Casher, RN. After noticing a drop in attendance at Mercy Hospital in Portland, ME, Casher aimed to help determine the most common barriers HF patients face.

The results found that 46 percent of discharged HF patients were unable to attend their follow-up appointments due to lack of affordable, accessible and reliable transportation. By establishing a source of transportation prior to discharging HF patients, Mercy Hospital increased attendance from 75 percent in Q1 2016 to 86 percent in Q4 2016.

A total of 25 posters featuring best practices from the ACC Patient Navigator Program were presented at NCDR.17. Other contributing hospitals included: Mercy Medical Center, Des Moines, IA; Einstein Medical Center, Philadelphia, PA; Aurora BayCare Medical Center, Green Bay, WI; Barnes-Jewish Hospital, St. Louis, MO; Wyoming Medical Center, Casper, WY; Newark Beth Medical Center, Newark, NJ; Indiana University Health-Methodist Hospital, Indianapolis, IN; Advocate Sherman Hospital, Elgin, IL; Olathe Medical Center, Olathe, KS; Indian River Medical Center, Vero Beach, FL; UT Southwestern Medical Center, Dallas, TX;  Renown Health Institute for Heart & Vascular Health, Reno, NV; VCU Health, Richmond, VA; WakeMed Health and Hospitals, Raleigh, NC; Western Maryland Health System, Cumberland, MD; Christiana Care Health System, Newark, DE; Central Lynchburg General Hospital, Lynchburg, VA; UCLA Health, North Hollywood, CA;  University of Colorado Hospital, Aurora, CO; and Trident Medical Center, Charleston, SC. 

The College launched ACC Patient Navigator Program in 2014. Hospitals participating in ACC’s ACTION Registry-GWTG and the Hospital to Home Initiative are eligible to participate in the Patient Navigator Program. For more information, visit


Keywords: Animal Assisted Therapy, Appointments and Schedules, Documentation, Follow-Up Studies, Heart Failure, Hospital Units, Hospitals, General, Inpatients, Myocardial Infarction, Patient Care Team, Patient Compliance, Patient Discharge, Patient Navigation, Patient Readmission, Registries, Tomography, X-Ray Computed, Cardiology Interventions

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