The purpose of this pilot was to improve multidisciplinary coordination of care and patient education and foster self-management behaviors. The primary and secondary outcomes achieved from this pilot were to decrease the 30-day readmission rate and heart failure length of stay.
The primary practice site was an inpatient medical–surgical nursing unit.
The length of stay decreased from 6.05% to 4.42% for heart failure diagnostic-related group 291 as a result of utilizing the model. The length of stay decreased from 3.9% to 3.09%, which was also less than the national rate of 3.8036% for diagnostic-related group 292. In addition, the readmission rate decreased from 23.1% prior to January 2013 to 12.9%. Implementation of standards of care coordination can decrease length of stay, readmission rate, and improve self-management.
Implementation of evidence-based heart failure guidelines, improved interdisciplinary coordination of care, patient education, self-management skills, and transitional care at the time of discharge improved overall heart failure outcome measures. Utilizing the longitudinal model of care to transition patients to home aided in evaluating social support, resource allocation and utilization, access to care postdischarge, and interdisciplinary coordination of care. The collaboration between disciplines improved continuity of care, patient compliance to their discharge regimen, and adequate discharge follow-up.
Sabrina Marie White, DNP, MSN, APRN, ACNP-BC, received her Doctorate in Nursing from the University of South Alabama. Presently, she is a nurse practitioner in Heart Failure at East Jefferson Medical Center in Metairie, LA. She has practiced as a Heart Failure/Heart Transplant practitioner for 11 years and received the 2013 graduate award for her work in heart failure from Preventive Cardiovascular Nurses Association. She also worked as a faculty member, educating and shaping the minds of aspiring nurses at Charity School of Nursing and Louisiana State University in New Orleans, LA.
Alethea Hill, PhD, MSN, ANP-BC, is currently Assistant Professor at the University of South Alabama (USA) College of Nursing and an Adult Acute Care Nurse Practitioner in private practice. She obtained her BSN and MSN degree in Nursing from the University of South Alabama and received a PhD in Nursing from the University of Alabama at Birmingham. Her dissertation focused on the associations between perceived discrimination, allostatic load, and insulin resistance in nondiabetic African American women of the Jackson Heart Study. Dr. Hill's interest includes the impact of cardiovascular risk factors on health outcomes. She is also interested in the interconnectedness of social/environmental determinants of health and health disparities on cardiovascular health status.
Address correspondence to Sabrina Marie White, DNP, MSN, APRN, ACNP-BC, College of Nursing, University of South Alabama, University Boulevard, Mobile, LA 36688 (e-mail: email@example.com).
The authors report no conflicts of interest.