AHRQ Innovations Exchange | Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds

full-text ►AHRQ Innovations Exchange | Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds: "Postdischarge Followup Calls to Skilled Nursing Facilities Reduce Heart Failure Readmissions by Two-Thirds


Summary
United Hospital case managers telephone skilled nursing facility nurses within 48 hours of each heart failure patient's discharge to verify that appropriate care management is being provided, as laid out in the discharge orders. During these conversations, case managers confirm that staff weigh the patient each day and provide appropriate diet and medications, and that a physician followup appointment is scheduled within 3 to 5 days of hospital discharge. The case manager also answers any questions the nurse might have about ongoing care of the patient. The program significantly reduced readmissions, generating cost savings of more than $33,000 annually.

Evidence Rating
Moderate: The evidence consists of pre- and post-implementation comparisons of readmissions among heart failure patients discharged to skilled nursing facilities, along with an estimate of the associated cost savings from prevented readmissions.

Developing Organizations
United Hospital
St. Paul, MN

Date First Implemented
2009
July

Patient Population
Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)

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