A "navigator" program designed to help patients transition from hospital to outpatient care showed success in reducing readmissions and deaths and increasing the number of patients keeping follow-up appointments, based on findings presented Feb. 14 at ACC's Cardiovascular Summit in Orlando, FL.

Sanger Heart & Vascular Institute in Charlotte, NC, established its Heart Care Navigation Team in 2017 with the goal of reducing unnecessary readmissions, improving mortality and improving patients' experience. Patients in the program are assigned a health advocate and a nurse navigator who meet the patients while they are in the hospital. The nurse navigator calls the patient within 24 to 48 hours of discharge, and then every two to four weeks for 90 days, to help with timely access to follow-up care, promoting self-management and addressing patients' questions or concerns.

In the study, researchers compared data from 560 patients treated for a myocardial infarction between July 2016 and June 2017, before the program began, to 421 patients treated in the year after the program was implemented (July 2017 to June 2018). Results showed that the 30-day readmission rate before the program started was 6.3 percent and fell to 3.7 percent the year after the program began. There was a reduction in the 30-day death rate (5.75 percent before vs. 4.57 percent after program implementation) and an increase in patients' follow-up appointments made prior to discharge (78 percent vs. 96 percent). The study also found an increase in guideline-based care from 83.3 percent to 85.1 percent, as well as an increase in cardiac rehab referrals (85.7 percent vs. 88.6 percent).

"Before the program was implemented, the discharging nurse would provide discharge education, cardiac rehab would provide education and the patient would be sent on their way," said Amber Furr, BSN, RN, CPHQ, performance improvement coordinator at Sanger Heart & Vascular Institute. "This study shows that nurse navigators are an integral part of reducing heart attack readmission and mortality. We're not where we want to be yet with cardiac rehab referrals or guideline-driven care, but we have seen an improvement."

Keywords: CV Summit, Patient Readmission, Patient Navigation, Patient Discharge, Patient Transfer, Ambulatory Care, Myocardial Infarction

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