Collaborative Effort to Reduce Readmissions at Griffin Hospital

Griffin Hospital is the flagship hospital for Planetree, Inc., an organization that promotes patient-centered care.

The Problem
Griffin Hospital determined that there were too many readmissions for patients with congestive heart failure. Hospital leaders realized they needed to extend their patient-cen¬tered model of care into the community and partner with long-term care organizations. The began by reaching out to nursing homes and home health facilities to gain a better understanding of each organization's role and the factors contributing to readmissions. Through this process, the hospital learned that (1) patients had too much sodium in their diets, a factor in many readmissions for CHF, (2) there were neither consistent programs for home care services after discharge nor follow-up with primary care and cardiac physicians and (3) each organization used different teaching tools and protocols.

The Solution
The hospital invited skilled nursing facilities and home health agencies to join a collaborative effort to reduce readmissions. This collaborative, Valley Gateway to Health, implemented a shared model of care transitions with standardized teaching tools and protocols for patients and providers.
Per the new protocol, patients with congestive heart failure who arrive at the emergency department are seen by a multidisciplinary team consisting of a cardiologist, nutritionist, case manager and pharmacist. Each team member meets with the patient prior to discharge and ensures that the patient understands medical prescriptions, diet plans and exercise needs and recognizes which symptoms require a call to the cardiologist or primary care physician. An outpatient congestive heart failure clinic provides intravenous medications since many nursing homes are not licensed to do so. The hospital follows up with patients and nursing homes weekly for one month after discharge. Physicians were trained to provide information at discharge in ways that patients can understand. The teach-back program was implemented, using a brochure developed by the University of North Carolina. The brochure provides information on actions patients can take to prevent readmissions. Nursing homes and home health facilities use the same brochure so that patients receive a consistent message.

The Result
Congestive heart failure readmissions fell from 15 percent to 7 percent during the course of the project. From 2010 through 2011, the internal heart failure readmissions decreased from 13.2 percent to 8.6 percent, and heart failure to any readmission decreased from 30.2 percent to 23 percent.

Lessons Learned
The congestive heart failure population is largely elderly, so it is important to identify and educate members of a patient's support system.

This case study was originally featured in the HPOE guide: 'Engaging Health Care Users: A Framework for Healthy Individuals and Communities,' published January, 2013.