Increasing patient support for chronic heart failure self-management through structured telephone support: a quality improvement project

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Montana State University - Bozeman, College of Nursing


Background: Chronic heart failure (CHF) affects an estimated 6.2 million Americans and is the leading cause of hospitalization in adults older than 65 in the U.S. and has the highest 30- day readmission rate among all surgical and medical conditions. Experts suggest nearly 25% of these readmissions are preventable. Problem: A clinic in northwest Montana has a higher than the national CHF readmission rate. The clinic follows current guidelines for post-hospitalization follow-up. Evidence shows supplementing usual care with structured telephone support (STS) is an effective method for decreasing readmission rates. Methods: All CHF patients of the clinic are called within three days of hospital discharge to be enrolled into the STS program. The Care Coordinator calls the CHF patients twice weekly using the STS template to provide support for CHF self-management. The content of each biweekly call is documented using the STS template. Results: No patients were enrolled in the STS program during the eight-week QI implementation period. Two CHF patients were discharged but were not enrolled into the program for various reasons. Discussion: Inconclusive results related to insufficient data does not inherently mean this project provides no value. Recommendations were derived from the results of this QI project that may be useful for future STS QI projects. This project revealed that not all recently discharged CHF patients are good candidates for STS and the importance of developing candidate inclusion criteria.




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