Jacobs Barbara
Heart Center at United Hospital in Saint Paul, Minnesota 55102, USA.
Prof Case Manag. 2011 Jan-Feb;16(1):18-24; quiz 25-6. doi: 10.1097/NCM.0b013e3181f3f684.
PURPOSE/OBJECTIVES: Readmission rates for heart failure patients are a Center for Medicare & Medicaid and Joint Commission core measure. At this urban Midwestern medical center, the 6-month baseline skilled nursing facility (SNF) readmission rate was 30%. Nurse case management implemented a process to decrease the rate for this population. Follow-up phone calls were in place for patients discharged to home, but a gap remained in those discharged to SNFs. Nurse case management developed a follow-up phone call process within 48 hours of discharge to the registered nurse/licensed practical nurse in the SNFs to verify that: 1. Daily morning weights were ordered. 2. Parameters to contact primary care provider if weight gain was greater than 3 pounds per day or 5 pounds per week. 3. 2 gram sodium restricted diet was ordered. 4. Appropriate diuretic was ordered and reconciled. 5. Follow-up provider visits were made, for patient to be seen within 3 to 5 days following discharge.
Acute inpatient care settings.
FINDINGS/CONCLUSIONS: The phone calls resulted in improved continuity of care and clarification of discharge orders. The opportunity for question-and-answer time between the hospital and the SNF nurse provided just-intime education; relationships have also been strengthened. Recent data show that the current readmission rate averages 11.32% (a decrease from 30%). This nurse case management–driven process of follow-up phone calls between the hospital and SNF staff to reduce readmission rates in heart failure patients resulted in improved continuity of care and clarification of discharge orders.
This simple, innovative process allowed for improved continuity of care and partnerships between inpatient hospitalization and the SNF, thereby reduced transcription errors and improved patient health outcomes. Enhanced communication between providers allowed for a significant reduction in readmissions from SNFs to the hospital.
目的/目标：心力衰竭患者的再入院率是医疗保险与医疗补助服务中心以及联合委员会的一项核心指标。在这家位于美国中西部的城市医疗中心，6个月的基线熟练护理机构（SNF）再入院率为30%。护士病例管理部门实施了一项降低该人群再入院率的流程。对于出院回家的患者，已经安排了随访电话，但对于出院到SNF的患者仍存在差距。护士病例管理部门制定了一个在出院后48小时内给SNF的注册护士/执业护士打电话的随访流程，以核实：1. 已安排每日晨重测量。2. 如果体重每天增加超过3磅或每周增加超过5磅，联系初级保健提供者的参数。3. 已安排2克钠限制饮食。4. 已开出并核对了适当的利尿剂。5. 已安排随访提供者就诊，患者在出院后3至5天内就诊。
急性住院护理环境。
研究结果/结论：这些电话改善了护理的连续性并澄清了出院医嘱。医院与SNF护士之间的问答时间提供了及时的教育；关系也得到了加强。最近的数据显示，目前的再入院率平均为11.32%（从30%下降）。这种由护士病例管理驱动的医院与SNF工作人员之间的随访电话流程，以降低心力衰竭患者的再入院率，改善了护理的连续性并澄清了出院医嘱。
这个简单、创新的流程改善了护理的连续性以及住院治疗与SNF之间的合作关系，从而减少了转录错误并改善了患者健康结局。提供者之间加强的沟通使SNF到医院的再入院率大幅降低。
