Complications from heart failure are among the most common causes for a readmission. Research shows that about 20% of heart failure patients return to the hospital within a month after discharge.
That's why home health provider Amedisys has launched a program to help heart failure patients better manage their health and well-being so they are less likely to visit the ED unnecessarily. The program, which began last year, encourages patients to keep a daily record of their blood pressure, weight and other symptoms associated with the disease, like shortness of breath.
The daily exercise helps patients "to really take ownership of their own health; they know what they are doing, and they are in control," said Shannon Abbott, vice president of specialized clinical programs at Amedisys.
The logbook also has a section where patients list both short- and long-term goals. Family members are involved in this process as well. Examples of goals set by patients are to lose weight, walk down the aisle at their daughter's wedding without a walker and to get back on the golf course. When patients reach goals, "they are really quite proud of themselves," said Susan Sender, Amedisys' senior vice president and chief clinical officer. "It empowers them to want to continue."
The logbook also includes educational information about heart failure, including the disease process, the difficulties of daily living associated with the illness and tips for a healthy diet like avoiding foods high in sodium.
Finally, information about the importance of psychological well-being is included along with available community resources. "Heart failure patients can get very depressed while they are dealing with this disease," Abbott said.
The patients are told to bring the logbook with them to doctor's appointments. Amedisys clinicians even sometimes accompany patients on visits to tell the doctor more about the program. "The physicians are pleased to see a home health agency make such a commitment for the long-term health of their patients," Sender said.
The average time Amedisys cares for patients is about two months, so the goal is for patients to continue using the skills taught in the program long after discharge.
Patients are also given an adhesive placard that categorizes severity of symptoms by using the colors green, yellow and red. Patients are told to put it in a spot in their home that they frequently pass so they can always review their symptoms and ensure they are in the normal range, or if they should seek medical help.
About 13,000 Amedisys clinicians treat roughly 100,000 heart failure patients in 34 states every year.
The clinicians have been trained to introduce the program to all their heart failure patients and it has changed the patient visit dramatically, Abbott said. Instead of the "doing it for you" mentality that characterized the clinician-patient relationship, visits are about how patients can continue to work toward their goals themselves, she said.
Amedisys developed computer-based courses to train clinicians to appropriately introduce and apply the program. They are taught to focus on patients' opportunities to improve as well as times to celebrate progress.
"The whole thing is about empowering the clinician to recognize the ability in their patients," Sender said.
The skills related to "empowerment" are now part of Amedisys' orientation program so clinicians can apply them to any of their patients regardless of their disease, she said.
Amedisys has reported positive outcomes from the program so far. In a February analysis, the company found that high-risk heart failure patients who participated in the program were 5% less likely to be hospitalized after 30 days and 8% less likely after 60 days. Moderate-risk heart failure patients were approximately 4% less likely to experience a readmission after 30 days and 3% less likely after 60 days. The analysis included 22,675 heart failure patients in 34 states.
Sender said patients also reported improvement in functional status like improved breathing and mobility. "Across the board, we are seeing improvement in these patients' outcomes," she said.