HEART FAILURE CARE PLAN

Reduces heart failure readmission rates and increases patient satisfaction

Heart failure is a serious and chronic condition that requires patients to make lifestyle changes for better health. Patients that fail to make the necessary changes in diet, exercise and lifestyle are at risk for readmission to the hospital and poor health in the future. USA Today reports that, one of every four heart failure patients must be readmitted within 30 days of discharge. The high rate of readmission for heart failure patients results from their inability to adequately self-manage the condition, according to the Agency for Healthcare Research and Quality (AHRQ).

Prevent Readmissions
Preventing heart failure readmissions starts with teaching patients about their condition. Patients proceed at their own pace through the four phases of the Heart Failure Care Plan. The first of the four phases teaches patients about their diagnosis and medications. The second phase communicates the importance of taking their medication and what signs and symptoms to observe. The third phase focuses on nutrition and exercise. The fourth and final phase discusses healthy lifestyle changes and reviews education from previous phases. This comprehensive curriculum for heart failure education empowers the patient to understand their condition and better care for themselves at home to stay out of the hospital.
GetWellNetwork Heart Failure Care Plan prompts patients to participate in their heart failure education

Decrease the Cost per Case

Heart failure readmissions can mean a financial loss for the hospital when

We are optimistic that by actively engaging heart failure patients in this comprehensive care plan, we will see fewer patients coming back to the hospital thirty days post discharge. Monica C. Bologna, BSN, RN, CCRN-CSC
SENIOR DIRECTOR OF CARDIAC SERVICES WEST JEFFERSON MEDICAL CENTER

Medicare introduces its Bundled Payment system. Under the new health law, hospitals will be responsible for the patients care for up to 30 days post discharge. This means that hospitals will not receive payment for heart failure patients readmitted within 30 days of discharge. According to the AHRQ, Medicare Heart Failure patients are the leading cost per case liability with 24.7% returning within 30 days. By preventing these readmissions, hospitals can reduce the cost per case of heart failure patients thereby improving profitability.

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Improve Quality and Satisfaction

With the passage of new health care laws, CMS will introduce the Value Based Purchasing Program hospital reimbursement will be impacted by performance based on HCAHPS and Care Measures. The GetWellNetwork Heart Failure Care Plan provides education to patients that can make an impact on satisfaction and Care Measures. Specifically, the Heart Failure Care Plan addresses the heart failure discharge instruction and readmissions rate Care Measures as well as two HCAHPS questions; #20, Was given information regarding what to do during recovery at home. and #16, Staff always explained new medications.

Track Patient Progress

The patients progress with the Heart Failure Care Plan is recorded and available for reporting from the GetWellNetwork Management Console. Progress and tasks can also be automatically documented to the patients EMR. Nurses and staff can monitor the patients real-time progress and help them stay on course To quickly identify patients that need assistance, staff can access overview reports that monitor the progress of all patients using the Heart Failure Care Plan.

Heart Failure Care Plan Overview

The Heart Failure Care Plan consists of four phases. Each phase contains multiple steps to be completed throughout the day. Patients progress at their own pace with the option of revisiting any part of the care plan. Patient comprehension is measured throughout each phase. Overview of Care Plan Literacy Assessment Diagnosis Medications Discharge Preparation Checklist Patient Activation Measure Questions and Daily Overview Self Assessment of Signs and Symptoms Diet and Nutrition Exercise Medications (side effects) Building Lifestyle Change Plan Questions and Daily Overview

Phase 1

Phase 2
Signs and Symptoms Education Medication Adherence Test Results Lifestyle Change Questions and Daily Overview

Phase 3

Phase 4
Self Assessment of Signs and Symptoms Reinforcement of Prior Lessons Overcoming Challenges in Lifestyle Patient Activation Measure

The Heart Failure Care Plan makes use of Milner Fenwick HealthClips to educate the patient about understanding their condition, signs and symptoms, medications, and the importance of a healthy lifestyle.

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GetWellNetwork uses the bedside TV to entertain, educate and empower hospital patients and caregivers to be more actively engaged in their care. This patient-centered approach improves both satisfaction and outcomes for patients and hospitals. GetWellNetwork is the leader in interactive patient care solutions and is exclusively endorsed by the American Hospital Association. GetWellNetwork, Inc. 7920 Norfolk Avenue, 10th Floor Bethesda, Maryland 20814 2010 GetWellNetwork, Inc. Toolkit-HF-07-10