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Best-practice pathway improves quality of life for heart failure patients

Behind every successful outcome story, there is a high-functioning, dedicated team at work. That is certainly the case at Washington Health System (Washington, Pennsylvania, U.S.A.), where a multidisciplinary team has significantly improved outcomes for patients with congestive heart failure (CHF) with a consistent, best-practice pathway in Allscripts Sunrise™.

Critical role of Heart Failure Navigators, teamwork

A recent case study details the approach Washington Health System used to improve the quality of life for patients with CHF. “We developed a structured approach, or pathway, incorporating best-practice elements into our program to improve the quality of care for CHF patients during acute hospitalization,” Director of Clinical Integration Maureen Smith, RN, M.S., said. “Our goal is to reduce unwarranted variation in the delivery of care, improve patient outcomes, decrease readmission rates and length of stay, as well as improve the patient experience.”

Since the start of the program in 2016, Washington Health System has hired two nurses to serve as Heart Failure Navigators. They provide comprehensive education and care management for patients enrolled in the program. They meet with patients during their inpatient stay, and includes family members, to acquaint them with her role in helping patients transition to outpatient self-management.

At discharge, the navigators review the patient record, schedule a follow-up physician visit and document it on a template for the outpatient electronic health record (EHR). Using protocols developed by cardiologists, the navigators stay in close contact with patients to monitor symptoms and adjust medications at home as needed. If the patients do not adequately respond to these adjustments, they go to a Heart Failure Clinic for assessment, IV diuretic dose and evaluation. These visits are designed to avoid unnecessary emergency room visits and hospitalizations.

“We’re very proud of this program, and many disciplines have put in a lot of time and effort,” Smith said. “Our physician champion is a great leader and our navigators are well-respected nurses from our critical care unit…everyone really came together to develop an excellent program that our physicians look to for resources for these patients.”

Harry “Dave” Frye’s story

One patient enrolled in the program was Harry “Dave” Frye. His son, David, wrote a letter to Washington Health System to express his gratitude, including this excerpt about his father’s experience:

During a visit to Hospital he met with Shelly, the Congestive Heart Failure Program’s Nurse Navigator, and agreed to enroll in the program.

Over the following weeks, my father spoke with Shelly frequently. If he gained weight, he called her. If his vital signs worsened, he called her. If he had a question, he called her. With the protocols in place and having a clinical person to speak to, there was no waiting nervously to find out what we could do. She was available to provide answers immediately. They frequently adjusted his medications, calling in new prescriptions if needed.

On three separate times he came to the Congestive Heart Failure Urgent Care Clinic at the Hospital to receive IV diuretics, and then was able to return home. Before, each of those visits would have meant a trip to the emergency room for my father, followed by a hospital admission for diuretics for one to two days. Instead he was able to walk right into the clinic, get what he needed, and go home.

My father was enthusiastic about what a wonderful program the Congestive Heart Failure Clinic is. In his own words, “It just makes sense.” He was tired of spending his days in the hospital. Trying to make adjustments to his treatment plan through phone calls to the doctor’s offices was slow and inefficient. With the added support the clinic provided him, he was able to better manage his heart failure and spend more time at home….

In the two months he was enrolled, he did not have to spend a single day in the hospital until the day of his passing. His quality of life was improved, as was his peace of mind.

These invaluable outcomes are only possible with the unwavering commitment of dedicated care teams. For more information about Washington Health System’s success in creating a consistent pathway for patients with CHF, download this case study.

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