REDUCING HOSPITAL READMISSIONS FOR CONGESTIVE HEART FAILURE PATIENTS: A QUALITY IMPROVEMENT PROJECT IN A HOME HEALTH AGENCY

Abstract

The cost of care for congestive heart failure (CHF) patients can be greatly reduced by utilizing home health services. However, baseline data analyzed on initial chart review of patients admitted to one local home health agency showed that interventions were not preventing rehospitalization within 30 days of hospital discharge. A gap in management of CHF patients was identified at the home health agency. Utilization of an evidence-based tool by clinical staff to instruct CHF patients on self-managing their care needed to be incorporated into the existing Pulmonary Disease Program (PDP). This quality improvement project sought to address this gap by integrating the evidence-based tool “Self-Check Plan for HF Management”. The outcome measurements evaluated were improvements in clinical staff adherence using this tool. The Plan-Do-Study-Act model was used to guide and evaluate the change process. Results showed that clinical staff improved adherence by 14% in teaching CHF patients at the initial visit using the tool. Clinical staff adding the tool onto the plan of care for CHF patients improved by 10%. Furthermore, a 23% improvement in clinical staff adherence was demonstrated with documentation that the tool was reviewed at the next follow-up visit. Therefore, clinical staff were prepared to continue utilizing a tool as part of their new Cardiopulmonary Disease Program (CDP) once it was integrated into the home health agency.