1. Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator

2. Memorial Hospital Pembroke is a full-service, fully accredited hospital. From emergency, medical and surgical care to innovative outpatient services, home health and educational programs, patients benefit from a full continuum of care.

3. “When you come to a fork in the road…. Take it”

4. Goal Decrease the Heart Failure 30 day readmission rate and associated costs. Improve patient outcomes by providing disease specific education and safe transition of care from hospital to next level of care.

5. The Road Led Us To… Executive level approval Identify Clinical Department Leader Identify Lead Clinical Care Coordinator Identify multidisciplinary team Identify Physician Champion Create educational material

6. The Road Led Us To… Set implementation date for inpatient program Coordinate with Nursing Educate all staff Train Clinical Care Coordinator on database Introduce program to Physicians Letter Physician dining room slide show Poster board Face to face presentation

7. Program Criteria

8. Patient Baseline interview Self assessment Identify personal goals Initiate Personal Health Record (PHR) with patient

9. Chart Information

10. Baseline Interview

11. Educate Education is empowerment Provide one on one inpatient and group classes Transition community education Coordinate care

12. Hospital Visits

13. Advocate Include Patient Family Centered Care Coordinate insurance Schedule Physician appointments Schedule outpatient testing / procedures

14. Communicate Discharge plan Personal Health Record (PHR) Instruct on follow-up appointments / procedures Post discharge telephonic communication

15. Personal Health Record (PHR)

16. Alerts

17. Phone Calls

18. The Road So Far…. Implemented the Care Coordination Program for Heart Failure January 2010. Enrolled 127 patients into program Jan-May 2010 250 hours of one to one education 60 interdisciplinary inpatient education classes 45 hours post hospitalization telephonic follow-up

19. Decreased the 30 day re-admission rate from 1 st Qtr 2008 to 1 st Qtr 2010 by 63% Quarterly Heart Failure Readmission Rate 12.9% 9.1% 4.8% (MHP to MHS)

20. The Road Leads To… Reduced readmissions Improved quality of care Improved quality of life

21. PATIENT FIRST Provide the Right Care, at the Right Time, for the Right Reason

22. QUESTIONS ? Contact Information Susan Levine RN Director of Clinical Resource Management sulevine@mhs.net Carolyn Timmons BSN, RN Clinical Care Coordinator ctimmons@mhs.net