A Knowledgebased Approach to Decreasing Chf Readmisssions Tailored to Individual Patients

1Coulmbia University, New York, NY
2New York Presbyterian Hospital, New York, NY

Meeting: Hospital Medicine 2012, April 1-4, San Diego, Calif.

Abstract number: 97697


Congestive heart failure (CHF) affects nearly 5 million people in US. Thirty day re–hospitalization rate for Medicare beneficiaries hospitalized for congestive heart failure is 27% of which 90% are unplanned. The reimbursement by CMS for these readmissions may be limited, placing a premium on improvement efforts in this area.


A pilot initiative aimed at reducing 30 days readmission rates and improving the overall care of our CHF patients was developed and implemented.


We assessed our patient population, available resources, current practices, and existing literature on decreasing readmission as a part of a clinical–educational initiative. We hypothesized that a comprehensive program pivoting around a registered nurse (RN) dedicated to all aspects of the transition of care for individual CHF patients would be the most beneficial approach. An RN Heart Failure Coordinator (RN–HFC) was hired for this role and subsequently trained by hospitalists. The RN–HFC established a close link with patients and their families, starting with bedside introductions, educational visits and individualized and group education protocols. Post–discharge activities included calling patients at 48–hour intervals until seen by their primary physicians. These follow up phone calls also focused on identification and troubleshooting of potential causes for readmission. Hence, patients were provided with continuous and tailored support that would have not been possible with just instrumental monitoring or a single phone call. From November 2010 to November 2011 the RN–HFC managed approximately 300 patients and reached 97% of them after discharge. The overall re–hospitalization rates for CHF patients dropped for comparable periods in these years from 25+% to 18%, with an estimated cost per patient at less than $500. The patients not reached after discharge had significantly higher readmission rates, although this sample size is too small for firm conclusions at the moment. Comorbidities, such as pulmonary disorders and chronic renal disease, as well as delayed first follow–up visit were readmission predictors, as reported earlier. We also observed preliminary indications of the increased satisfaction of patients and their families.


The preliminary results of our program are very encouraging. They indicate that a dedicated RN–HFC comprehensively handling the education of patients and their families and the transition to the primary care doctors can reduce readmissions, increase satisfaction of patients and their families, and improve overall quality of care.

Chart 1A 30–day readmission rates for CHF for Allen Hospital (6–months rolling averages; broken horizontal lines are monthly readmission averages for periods covering matching months; data for October may be subject to change) in 2010 and 2011.

To cite this abstract:

Barron B, Tinling–Solages D, Stugensky K, Placencia M, Wyer P, Stojanovic Z. A Knowledgebased Approach to Decreasing Chf Readmisssions Tailored to Individual Patients. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97697. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/a-knowledgebased-approach-to-decreasing-chf-readmisssions-tailored-to-individual-patients/. Accessed May 23, 2019.

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