1. Implementation of a Patient Navigator Program to Reduce 30-day Heart Failure Readmission Rate
- Author
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Katherine E. Di Palo, Ileana L. Piña, Khusbu Patel, and Manaf Assafin
- Subjects
Male ,Patient Transfer ,Health Knowledge, Attitudes, Practice ,Time Factors ,Acute decompensated heart failure ,Psychological intervention ,Pharmacist ,Health literacy ,Nursing Staff, Hospital ,030204 cardiovascular system & hematology ,Pharmacists ,Nurse's Role ,Patient Readmission ,Medication Adherence ,03 medical and health sciences ,0302 clinical medicine ,Patient Education as Topic ,Predictive Value of Tests ,Risk Factors ,medicine ,Humans ,Patient Navigation ,030212 general & internal medicine ,Aged ,Retrospective Studies ,Aged, 80 and over ,Heart Failure ,Patient Care Team ,Ejection fraction ,Delivery of Health Care, Integrated ,business.industry ,Middle Aged ,medicine.disease ,Patient Discharge ,Self Care ,Clinical pharmacy ,Heart failure ,Female ,Medical emergency ,Cardiology and Cardiovascular Medicine ,Heart failure with preserved ejection fraction ,business ,Risk Reduction Behavior ,Biomarkers ,Program Evaluation - Abstract
With increasing awareness to provide personalized care our institution applied the American College of Cardiology (ACC) Patient Navigator Program to identify hospitalized heart failure (HF) patients and improve transitions and outcomes. Utilizing a Navigator Team (NT) composed of a nurse and clinical pharmacist, we delivered evidenced-based interventions and hypothesized this approach would improve identification of HF inpatients and reduce the 30-day all-cause readmission rate. Patients were followed from admission to discharge and received at least one intervention, tailored to the patient's health literacy and social needs. The 30-day all-cause readmission rate was 17.6% for the Patient Navigator Program and 25.6% for the medical center. Compared to the medical center there was a statistically significant increase in education and follow-up. For patients who received specific NT interventions of education and follow-up the readmission rate was 10.3% and 6.1% respectively. Hospital programs can easily embed a NT into existing initiatives to further reduce the readmission rate.
- Published
- 2017
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