Keywords

acute care, cardiac rehabilitation, case management, evidence-based practice, health care continuum, heart failure follow-up telephonic coordinator, home health care, outcome improvement, patient education to promote self-care

Authors

1. Miranda, Mary Beth RN, MS
2. Gorski, Lisa A. MS, RN, CS, CRNI
3. LeFevre, Jacqueline G. RN
4. Levac, Kathleen A. RN, MS
5. Niederstadt, Jennifer A. RN, MS, APRN
6. Toy, Anne L. MS, RN

Abstract

A coordinated initiative for patients with heart failure was planned and implemented across this healthcare system to: (1) incorporate best evidence-based practice to rapidly stabilize the patient, and (2) establish early, coordinated patient education to promote self-care at home with the support of appropriate resources. Length of stay, readmission frequency, ACE inhibitor and beta blocker prescribing patterns at discharge were the outcomes selected for ongoing study and cross-site efforts toward improvement. These outcomes did improve following cross-site implementation with the collaboration of all appropriate disciplines and the coordination of new and existing services to serve this population.