Sabrina's Article

Professional Case Management
Vol. 19, No. 6, 276-284
Copyright 2014 © Wolters Kluwer Health | Lippincott Williams & Wilkins
276 Professional Case Management Vol. 19/No. 6
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
H
eart failure is a chronic disease for which there
is no cure. Effective management of heart
failure is crucial in preventing recurrent
hospitalizations and decreasing the length of stay.
Investigators have studied methods for reducing
readmission rates to decrease the burden of hospi-
talizations and reduce cost for health care systems
for years (Zaya, Phan, & Schwarz, 2012). However,
readmission rates remain high and seem unabated. As
a result, Medicare initiated reimbursement penalties
for facilities with rates greater than the national rate
of 24.7% (U.S. Department of Health and Human
Services, 2012). Innovative strategies in heart failure
management are imperative to reduce readmission
rates and prevent penalties. Although hospital length
of stay among this population is not a primary end
point for Medicare at this time, the advent of future
tracking is possible. Approximately half of all read-
missions are preventable and result from inadequate
teaching, nonadherence, or inadequate postdischarge
follow-up (Manning, 2011).
The pilot project was implemented at a metro-
politan hospital in New Orleans, LA. Although the
institutional review board approval was waived
at this site, the institutional review board approval
was obtained at The University of South Alabama in
Mobile, AL. The length of stay for the heart failure
diagnostic-related group (DRG) 291 and 292 was
6.05 and 3.9, respectively. These rates were greater
than the national geometric length of stay of 4.7198
for 291 and 3.8036 for 292 (DRG Expert, 2012).
However, the readmission rate was 23.1%, which
is slightly less than the national average of 24.7%.
Although Medicare penalties were not incurred, the
narrow margin for incurring penalties demonstrated
an opportunity for improvement. The institution has
a large indigent and low health literacy population,
Address correspondence to Sabrina Marie White, DNP,
MSN, APRN, ACNP-BC, College of Nursing, University of
South Alabama, University Boulevard, Mobile, LA 36688
(e-mail: sabrinaw38@aol.com).
The authors report no conﬂicts of interest.
A B S T R A C T
Purpose/Objectives: The purpose of this pilot was to improve multidisciplinary coordination of care and
patient education and foster self-management behaviors. The primary and secondary outcomes achieved from
this pilot were to decrease the 30-day readmission rate and heart failure length of stay.
Primary Practice Site: The primary practice site was an inpatient medical–surgical nursing unit.
Finding and Conclusions: The length of stay decreased from 6.05% to 4.42% for heart failure diagnostic-
related group 291 as a result of utilizing the model. The length of stay decreased from 3.9% to 3.09%, which
was also less than the national rate of 3.8036% for diagnostic-related group 292. In addition, the readmission
rate decreased from 23.1% prior to January 2013 to 12.9%. Implementation of standards of care coordination
can decrease length of stay, readmission rate, and improve self-management.
Implications for Case Management Practice: Implementation of evidence-based heart failure guidelines,
improved interdisciplinary coordination of care, patient education, self-management skills, and transitional care
at the time of discharge improved overall heart failure outcome measures. Utilizing the longitudinal model of
care to transition patients to home aided in evaluating social support, resource allocation and utilization, access
to care postdischarge, and interdisciplinary coordination of care. The collaboration between disciplines improved
continuity of care, patient compliance to their discharge regimen, and adequate discharge follow-up.
Key words: coordination of care, heart failure, readmission rates, transitional care
A Heart Failure Initiative to
Reduce the Length of Stay and
Readmission Rates
Sabrina Marie White, DNP, MSN, APRN, ACNP-BC, and Alethea Hill, PhD, MSN, ANP-BC
DOI: 10.1097/NCM.0000000000000059
PCM-D-14-00012_LR 276PCM-D-14-00012_LR 276 9/24/14 1:55 AM9/24/14 1:55 AM

Vol. 19/No. 6 Professional Case Management 277
Approximately half of all readmissions
are preventable and result from
inadequate teaching, nonadherence, or
inadequate postdischarge follow-up.
which contributes to the patient’s inability to effec-
tively manage their disease process. The aim of this
article was to discuss factors that may contribute to
process improvement for patients with heart failure,
introduce a multicomponent process of care for the
institution, and explore process implementation.
PROCESS IMPROVEMENT FOR THE PATIENT WITH
HEART FAILURE
The stakeholders, administrators, physicians, and
management identified a need to improve care for
the population with heart failure. The institution’s
practice before implementing the model consisted of
two separate physician teams medically managing
the patients. The heart failure disease management
team and hospitalist utilized different standards of
care. In addition, the nurses provided very little docu-
mentation on the education patients received, except
for distributing an educational pamphlet upon dis-
charge. Interdisciplinary consults were available and
depended on the hospitalist-on-duty at the time of
admission.
Alternatively, the disease management team pro-
vided interdisciplinary care inclusive of a standard
order set, which included social services, occupational
therapy, physical therapy, and dietician consults
at the time of admit. Case managers automatically
identified patients with heart failure and began dis-
charge planning on admission to the medical–surgical
nursing unit. In addition, the team provided educa-
tion postdischarge in the clinic setting. The coordi-
nation of care provided was disjointed and evidence
of patient education was absent, yet crucial, for suc-
cessful patient self-management. The imperative dis-
covery for this model is the following question: Does
implementing innovative care models improve heart
failure patient outcomes, thus reducing readmission
rates, length of stay, and self-management behaviors?
The process was initiated as a result of chart
audits performed by the management staff and project
leader. Various deficiencies in standards of care were
identified. The components identified were a lack of
documented weights, intake and outputs, omission
of medication without written justification, and pro-
longed length of stay due to delayed laboratory or
diagnostic tests ordered by physicians. Standards of
care deficiencies, lack of coordination, and education
were identified as areas requiring improvement. The
project leader nurse practitioner with 12 years’ expe-
rience in advanced heart failure worked closely with
the interdisciplinary team. Meetings with stakehold-
ers were initiated to discuss chart audit findings and
viable strategies to correct the deficiencies.
The project leader performed a “Needs Assess-
ment,” which included the following analysis: (a)
SWOT analysis; (b) Gap analysis; (c) Dartmouth’s
5 P’s microsystem assessment; (d) Institute of Medi-
cine AIMS analysis; and (e) process mapping. The
assessment provided supporting evidence that a pro-
cess change was needed. A case report was included,
which identified deficiencies within the system uti-
lizing the extant process from admit to discharge.
The stakeholders were receptive to the needs assess-
ment and identified deficiencies. A comprehensive
literature search was performed to identify evidence-
based practice approaches utilizing MeSH terms
such as heart failure, interdisciplinary disease man-
agement, case management, coordination, clinical
pathway, critical pathway, standard order sets, order
sets, standard order, telephone management, and
transitional care. The vast majority of the evidence-
based practice literature incorporated several differ-
ent methods to managing the population with heart
failure.
Needs Assessments
A SWOT analysis was performed, which evaluated
the institution’s strengths, weaknesses, opportunities,
and threats. The strengths identified were access to evi-
dence-based tools for heart failure, flexibility among
staff to assume multiple roles, high engagement of
staff with patients and caregivers, academic center
with access to multiple disciplines, well-trained health
care providers with state-of-the-art equipment and
high levels of technical skills, The Joint Commission-
accredited facility, and affiliations with multiple higher
education institutions for student affiliations.
Weaknesses included codependence on specific
individuals with key skills, lack of continuity of
care due to disjointed resources, management style
and communication, low socioeconomic population,
higher readmission rate among patients managed
by providers outside of the heart failure team, lack
of evidence-based heart failure teaching protocols,
high comorbidities yielding advanced stage disease
processes, and difficulty obtaining transitional care
appointments. In addition, the department structure
was deficient because of staffing, acuity, time man-
agement, and staff education.
Opportunities perceived after evaluating the
strengths and weaknesses included the following:

• improving patient and caregiver education
and transition to home,
• educating nurses on standards of care,
• implementing a clinical pathway to improve
education and transition to home,
• financially optimizing current resources to
provide education and transition,
• coordinating and collaborating with case
management and social services to identify
patients and caregivers who may need
additional resources or alternate living
arrangements,
• educating home health agencies and
transitional care facilities on the clinical
pathway and callback form and their roles in
identifying transitional care issues requiring
attention, and
• an opportunity to become The Joint
Commission-accredited heart failure program.
Perceived threats identified without implement-
ing the process improvement initiative included
incurring Medicare 30-day readmission penalties,
growing uninsured indigent population, competing
hospital growth of facilities within the metropolitan
area, lack of adequate capital funding, low literacy,
and an increase in mortality and morbidity rates.
A gap analysis was also performed, which iden-
tified seven strategic objectives. These objectives
included the following:
1. patient education provided throughout the
hospital stay,
2. patient education upon discharge,
3. discharge planning,
4. medication reconciliation,
5. appointmentswithin1–2weekspostdischarge,
6. discharge to home health with telemonitoring
and/or a heart failure education program, and
7. telephone callback within 1 week of discharge.
Deficiencies were observed with providing inpa-
tient education. Although the patients received edu-
cation upon discharge, their retention of the infor-
mation was not assessed. Case managers were not
identifying social support needed to include in the
educational process and accountability for patient
care postdischarge, especially in the population
more apt to incur readmission within 30 days. Most
importantly, a large population of uninsured patients
was discharged without transitional care follow-up
to education programs in the community or home
health with telemonitoring. The action plan included
educating the nurses on the heart failure clinical
pathway and the evidence-based standards of care,
which were required for successful heart failure self-
management. Interdisciplinary coordination of care
between the case manager and the nurse practitioner
initiating the postdischarge call identified and evalu-
ated patient self -management and support postdis-
charge. Emphasis was placed on those who needed
alternative living arrangement to assist with self-
management initiatives, such as skilled nursing care
or long-term care.
Dartmouth’s 5 P’s microsystem needs assessment
was also performed. The 5 P’s focuses on the pur-
pose, patients, professionals, processes, and patterns.
The purpose identified was to improve heart failure
education and self-management, while decreasing the
30-day readmission rate and preventing reimburse-
ment penalties. The patients were all heart failure
patients and included the elderly, uninsured, low
literacy, and socioeconomic status, and those with
advanced disease and/or comorbid disease states.
These patients were noted to have a higher 30-day
readmission rates. The professionals participating
in the care of these patients during their hospital-
ization and postdischarge included physicians, resi-
dents, nurse practitioners, registered nurses, nursing
assistants, dieticians, case managers, social workers,
medical and nursing students, and allied health pro-
fessionals. The process identified as a need was heart
failure education provided in the form of a booklet at
the time of discharge. The booklet provided included
all of the evidence-based standards recommended by
the American College of Cardiology and American
Heart Association (ACC/AHA) joint position state-
ment. However, disseminating such large volumes
of information to patients who are already compro-
mised because of fatigue and inadequate oxygenation
may alter retention. Retention of information was not
evaluated at the time of discharge. The average length
of stay was 5.7, which was sufficient time to pro-
vide education in smaller increments in a structured
manner. The patterns identified included a majority
of elderly, African American population with 95%
below the poverty level. According to Hospitals
Compare, although the facility is below the national
readmission rate average of 24.7%, improvements
were needed to continue the current trend. The read-
mission rate as of July 2012 was 23.1%, down from
the previous year of 24%.
The Institute of Medicine aims were also used to
evaluate the standards in which we provided care to
the population with heart failure. All six specific aims
were evaluated, which included providing safe, effec-
tive, patient-centered, timely, efficient, and equitable
care. The needs identified as it pertained to these aims
are as follows:
1. safe care requiring a focus on collaborative,
competent heart failure management with
appropriate continuous quality improvement

processes to avoid injuries to the patient from
care that is intended to assist the patient;
2. effective care incorporating evidence-based
heart failure management and education
encouraging self-management behaviors to
reduceemergencyroomvisitsandreadmissions,
and avoiding overuse and underuse;
3. patient-centered care needed to be individual
and specific to the patient, evaluating biopsy-
chosocial and cultural needs incorporating
patient values;
4. timely care encompassing provision of
education and management within a time
frame during the acute care hospital stay
to foster self-management, thus preventing
recurrent exacerbations and decreasing hospital
readmissions;
5. efficientcarethatincorporatescurrentresources,
utilizing an interdisciplinary approach to
providing structured evidence-based care and
education, thus transitioning the patient to
home, and
6. equitablecareprovidingequalcaretoallpatients
regardless of extraneous factors such as race,
gender, beliefs, socioeconomic status utilizing
community resources, and collaboration to
ensure adequate follow-up.
The needs assessments performed for this pilot
project identified areas that were vulnerable and
required improvement for the population with
heart failure. Moreover, the assessment identified
standardized care, provided evidence-based educa-
tion during the acute care hospital stay, allowed
adequate discharge planning that began upon ini-
tial admit, and transitioned to home with adequate
resource utilization for those needing improve-
ments. A process map was used as a visual aid to
show the flow of implementation prior to initiation
of the project. The map depicted the actual execu-
tion of the process for clarity and quantification of
changes, which would be implemented and incorpo-
rated changes required as a result of findings from
the needs assessment.
MULTICOMPONENT MODEL OF CARE
Case Management and Social Services
Case management and social services played a vital
role in ensuring provision of resources from admis-
sion to discharge planning, achieving a seamless tran-
sition to home. Longitudinal case management was
utilized with collaboration between the inpatient
case manager and the outpatient nurse practitioner.
The patients’ discharge needs were assessed upon
admission to the unit by the case manager and social
services. Identification of family members or friends to
assist in providing social support was also performed
upon admit, especially for those patients at risk for
readmission. Resource utilization was a challenge for
some patients as they were uninsured. However, the
case managers coordinated access to private care and
community clinics, obtaining medications and rapid
processing of Medicaid applications for those who
did not have insurance. Those patients with insur-
ance were discharged to home health with arrange-
ments for telemonitoring. Furthermore, the roles for
these case managers were to coordinate transitional
care for a perplexed population of patients with vary-
ing degrees of transitional care needs. According to
Daley (2010), transitional care services to patients
requiring care across multiple settings can positively
impact outcomes.
Physician Order Set
The physician order set and clinical pathways were
created utilizing heart failure guidelines recom-
mended by the ACC/AHA (Jessup et al., 2009). The
order set was utilized by the heart failure team before
implementing the model. They were disseminated to
the hospitalist for their use as part of the model in an
effort to decrease inconsistencies in clinical practice.
Implementation of the order set improved multidisci-
plinary coordination of care, outcomes, and increased
adherence to evidence-based processes of care (Bal-
lard et al., 2010). The format utilized in the order set
includes laboratory and diagnostic tests required to
evaluate the causes of heart failure, medications to
be utilized as a standard of care, and specific nursing
duties. The order set also served as a venue to consult
other disciplines such as social services, dietary, occu-
pational therapy and physical therapy. These consults
were automatically triggered on admission to evalu-
ate and treat the patient with heart failure. Wagner
(2012) noted that there is less variability, more reli-
ability, and the correct provision of clinical care when
order sets are utilized.
Education Clinical Pathway
The clinical pathway utilizes an evidence-based
education format for the nurses to follow during
the acute care hospital stay. Clinical pathways have
proven to reduce variability in care and improve
adherence to guidelines, quality, efficiency, and
outcomes (Gardetto et al., 2008; van de Klundert,
Gorissen, & Zeemering, 2010). The topics included
in the clinical pathway utilized in this model are as
follows: (1) medications, (2) diet, (3) daily weights,
(4) warning signs, (5) exercise, and (6) heart failure
symptoms. These are topics recommended to achieve

the best possible self-management outcomes. Garin
et al. (2012) evaluated the use of clinical pathways
to disseminate evidence-based recommendations and
concluded that the use of the clinical pathway was
associated with a 28% reduction in relative deaths
and readmission rates and improved adherence to
guidelines. The model includes a 4-day clinical path-
way that was initiated on admission and incorpo-
rated reassessments of the patient’s knowledge at the
end of each shift.
Postdischarge Callback Form
The telephone interventions have been shown to
decrease rehospitalizations for heart failure by pro-
viding access to trained heart failure nurses and cli-
nicians (Staples & Earle, 2008). The post discharge
callback form was adopted from the American Heart
Association heart failure tools for education. The
tool was restructured to include terminology that an
average sixth-grade student could comprehend. The
form coincided with the information the patient was
taught during the acute care hospital stay and evalu-
ated the patient’s self-management knowledge and
utilization. Additional information such as the physi-
cian’s name, date of clinic appointment, readmission
status, and emergency room visit status was included.
There are two services admitting patients with heart
failure, however, and the patients are discharged to
three different hospital locations. The challenges
associated with following these patients postdis-
charge complements implementing the postdischarge
callback methodology.
PROJECT IMPLEMENTATION
The project included utilizing an evidence-based
order set and a clinical pathway for the nurses to
follow during the acute care hospital stay. The order
set and the clinical pathway were created utilizing
heart failure guidelines recommended by the ACC/
AHA. The patients received a follow-up phone call
within 48 hr after discharge utilizing a telephone
script adopted from the American Heart Associa-
tion (2011). The script coincided with the clinical
pathway and assessed the patient’s knowledge and
adherence to the education received during the acute
care hospitalization. The goal of the model was to
improve patient education utilizing a multidisci-
plinary approach, which includes physicians, nurses,
case management, social services, physical therapy,
occupational therapy, and dietician collaboration.
The multidisciplinary teams are automatically con-
sulted utilizing the heart failure standard order set
when admitted to the facility. The nurse then initiated
the heart failure education clinical pathway, which is
followed for the next 4 days. A dedicated heart fail-
ure nurse was not an option for administration, due
to hospital budget constraints. Therefore, more cre-
ative avenues were needed utilizing current staff and
resources. Improving self-care behavior and decreas-
ing length of stay and readmission rates were identi-
fied as outcomes used to evaluate the model.
The project team consisted of a nurse hospitalist,
case managers, social workers, a hospital administra-
tor, a core measures coordinator, and charge nurses
from the unit. The prephase of the project began in
October 2012, which consisted of monthly meetings
with the project team to coordinate project implemen-
tation. Implementation of the project coincided with
staff education of the “teach-teach back” method
of instructing patients, which deferred the initial
implementation date. The nurses were educated on
the “teach-teach back” method in December before
receiving the clinical pathway education session. A
trial utilizing the clinical pathway was performed
between January and March before beginning the
data collection phase to ensure adequate compre-
hension and utilization of the clinical pathway. The
clinical pathway education session began in January
with one general session during a staff meeting. The
clinical pathway was reviewed section by section and
the nurses were allowed to ask questions. In addition,
three–four huddle sessions were performed through-
out the day for the first 3 weeks to reinforce previous
education and answer any questions. These sessions
were performed at 6 a.m., 12 noon, and 6 p.m. to
capture nurses working on the day and night shifts.
During the first 4 weeks, the nurses were allowed to
utilize the clinical pathway as a guide to educate their
patients. This allowed the nurses to evaluate the tool
and make recommendation on practical use.
The project data collection began in February
2013; however, in March the initial clinical pathway
was revised as per recommendations from nursing to
delete the measures followed by the core measures
coordinator and the physicians due to redundancy.
In addition, identifying patients who were not diag-
nosed on admission but were diagnosed with new
onset heart failure patients were addressed. Encour-
aging the nurse’s input regarding the use of the clini-
cal pathway fostered the team concept and compli-
ance. The input resulted in the revision of the clinical
pathway. The clinical pathway was evaluated weekly
for application and completeness, while trending
those patients who were readmitted to the hospital
within 30 days of discharge. The patients were dis-
charged from the hospital and received a call from
the project leader within 48 hr after discharge to
assess their knowledge of heart failure and compli-
ance to their home regimen. Those patients requiring
additional education received telephone education on

any or all of the following topics: (1) medications, (2)
diet, (3) daily weights, (4) warning signs, (5) exercise,
and (6) heart failure symptoms. In addition, clinic
appointments within 1–2 weeks postdischarge were
evaluated and accommodations were made for those
without appointments. These topics were included in
the clinical pathway and evaluated utilizing the post-
discharge callback form. Additional phone calls were
allotted to reevaluate the patients’ identified defi-
ciencies or to talk to a caregiver who was providing
patient care in the home. The patients were evaluated
30 days postdischarge to determine whether they
visited the emergency room for heart failure or were
rehospitalized within the first 30 days.
The project was initiated in an uncustomary for-
mat in which staff were allowed to use the clinical
pathway before initiating data collection to become
familiar with the clinical pathway before collecting
data. This allowed easier transition into practice and
exposure to utilizing the clinical pathway prior to
implementation. The clinical pathway intervention
was included in the model to provide a structured
format for educating newly diagnosed patients with
heart failure. The success of the interventions was
evaluated utilizing the postdischarge callback form.
The heart failure readmission rate remains as
one of the outcome measures for this intervention, as
well as the information obtained from the callback
form. The standard order set is an additional inter-
vention, including diagnostic tests required to evalu-
ate the causes/treatment of heart failure, medication
to be utilized, and referrals to other disciplines as
recommended by the ACC/AHA heart failure guide-
lines. A measurement of success for this intervention
was the hospital length of stay. Early assessment,
evaluation, and treatment of heart failure causes can
decrease the length of stay and provide evidence-
based clinical application. The intrahospital clini-
cal pathway assessed the nurse’s interpretation of
the patient’s knowledge, utilizing the “teach-teach
back” method of education. And the postdischarge
assessment evaluated retention of the patient’s actual
knowledge.
SUMMARY AND IMPLICATIONS
The model was implemented utilizing a 4-day clinical
pathway that would accommodate the average length
of stay. Initially there were variances in the days
the patient’s clinical pathway began. The variance
occurred as a result of a subset of patients who were
admitted with a vague diagnosis requiring a medical
workup prior to a heart failure diagnosis. The patients
were diagnosed with heart failure after the first admis-
sion day and were later diagnosed as new onset heart
failure patients. These patients were included because
they were newly diagnosed heart failure patients,
despite the clinical pathway not being initiated on
admission. The project leader worked closely with
case management to identify these patients. The sec-
ond variance was in the number of days the patients
received education. This varied from 1 to 4 days
because of early discharge dates and times. These
patients were included to determine whether a shorter
length of stay would affect the readmission rate. How-
ever, only one of those patients was readmitted within
30 days postdischarge. The physician order set and
clinical pathway overall was instrumental in improv-
ing the standard of care and coordination of services.
A total of 59 patients were evaluated over the
course of 2 months. Clinical pathway utilization was
100% between the months of March through May. The
data collected in February were not utilized because of
clinical pathway revisions. Physician order sets were
also utilized 100% during this time frame. Postdis-
charge follow-up was performed within 48 hours of
discharge. In addition, four patients were admitted to
hospice or nursing homes, eight were readmitted to
the hospital, five phone lines were disconnected, and
one choose not to participate in the pilot. A total of
four patients required reeducation on one-or-more
topics and weekly phone calls for 2 weeks.
Statistical analysis of the callback form revealed
the following:
1. 90% of patients had appointments within
1–2 weeks of discharge,
2. 75% performed daily weight,
3. 93% were able to state the names of their
medications,
4. 95% were able to state their diet and foods
to avoid,
5. 100% were able to state the warning signs
associated with heart failure,
6. 100% were aware of their heart failure
symptoms,
7. 66% participated and understood the
importance of exercise,
8. 97% received an educational handout while
hospitalized, and
The intrahospital clinical pathway
assessed the nurse’s interpretation
of the patient’s knowledge, utilizing
the “teach-teach back” method of
education. However, the postdischarge
assessment evaluated retention of the
patient’s actual knowledge.

9. 80% of the patient actually had scales in the
home (see the Appendix).
None of these topics were addressed in a struc-
tured organized fashion before implementing the
model, and documentation was also not adequate.
The 48-hour callback form was instrumental in
assessing the education retained by the patient and
their self-management behaviors after discharge.
The areas requiring improvement were daily weights
and participating in exercise, which was less than
85% compliance. The 48-hour callback process was
one attribute of the longitudinal case management
concept.
The primary and secondary end points of imple-
menting the model were to decrease the overall length
of stay and readmission rate. The length of stay for
heart failure DRG 291 and 292 were primary end-
points for the project. DRG 291 length of stay was
6.05, which were above the geometric length of stay
of 4.7198. DRG 292 length of stay was 3.9 was also
above the geometric length of stay of 3.8036. The
average length of stay for the period January through
May was 4.42 for DRG 291 and 3.09 for DRG 292
(Hospital Corporation of America, 2013). These
are marked improvements from the initiation of the
education components of the model in January. The
readmission rate for patient data collected March
19 through May 19 revealed a readmission rate of
12.90%. The total readmission rate for the period of
time from initiation of education classes in January
until the end of the data collection time of May 19
was 12.08%. These numbers are significantly lower
than the December 2012 readmission rate of 23.1%
before initiating the model (U.S. Department of
Health and Human Services, 2012).
Despite improvements in the primary and sec-
ondary endpoints, limitations exist because of the
time frame data were collected. The initial data col-
lection period was only 4 months. However, because
of the institutions prior to education engagements to
implement the teach-teach back method, the educa-
tion sessions were delayed until January and revi-
sions occurred in March; this omitted data collected
in February because the tool was being revised. These
limitations did not affect sustainability, because the
project was implemented systematically. However,
the statistical data represent a short period of data
collection.
Implementation of the model was successful in
providing evidence-based practice guidelines for the
physicians and nurses to follow as they provide care
to the population with heart failure. These guidelines
were included in the heart failure order set and clinical
pathway, fostering improvements in multidisciplinary
coordination of care. Although implementing the
model was initially challenging, the results showed
improvements in all outcomes measures (length of
stay 30-day readmission rates, and self-management
measures). The outcomes also identified areas that
may require continued process improvements such as
daily weights and exercise. The order sets and clinical
pathways were instrumental in providing structured
processes and education for all patients admitted with
heart failure, therefore standardizing the processes
and reducing variances in the care provided by the
two teams caring for patients with heart failure at the
institution. Panella, Marchisio, Demarchi, Manzoli,
and Stanislao (2012) incorporated clinical pathways
as a measurement of education and self-management
and recommends integrating pathways at the point of
care, to reduce unwanted variations in practice.
The main clinical pearls attained from this proj-
ect supported utilizing evidence-based guidelines to
improve the care and education provided to patients
diagnosed with HF. The use of standard order sets,
clinical pathways, and a post discharge callback form
are an efficient and effective transitional care model
for improving self-management behaviors among HF
patients. Lastly, innovative HF strategies to manage
HF patients are individualized to the institutions and
are a viable means of providing care (see Box 1).
The order sets and clinical pathways
were instrumental in providing
structured processes and education
for all patients admitted with heart
failure, therefore standardizing the
processes and reducing variances in the
care provided by the two teams caring
for patients with heart failure at the
institution.
BOX 1
Clinical Pearls
Utilizing evidence-based guidelines can improve the care and education provided to patient diagnosed with HF.
The use of standard order sets, clinical pathways, and a postdischarge callback form are an efficient and effective transitional care model for
improving self-management behaviors among HF patients.
Innovative HF strategies to manage HF patients are individualized to the institutions and are a viable means of providing care.

Prior research has supported the utilization of tele-
phone interventions to assist with self-management
that consisted of postdischarge follow-up calls and
assessing the patient’s knowledge of their disease
management (Ferrante et al., 2010; Peters-Klimm
et al., 2010; Shearer, Cisar, & Greenberg, 2007). The
telephone intervention has been successful in reduc-
ing the readmission rates in combination with other
interventions. Although the pilot for this model was
only 2 months, allowing the nurses to utilize the clini-
cal pathway as a guide for educating the patient may
produce biases affecting internal validity. In addition,
there were no concrete processes in place to compare
the change despite the improvements in readmission
rates and length of stay that directly reflect patient
self-management behaviors. The model proved to be
useful in this institutions setting. This model exempli-
fies the usefulness of standardizing care for the popu-
lation with heart failure and identifies implication for
future research utilizing a multimodality approach.
REFERENCES
American Heart Association. (2011). Heart failure tools
and resources. Retrieved from http://www.heart.org/
hfclinicaltools
Ballard, D. J., Ogola, G., Fleming, N. S., Stauffer, B. D.,
Leonard, B. M., Khetan, R., & Yancy, C. W. (2010).
Impact of standardized heart failure order set on
mortality, readmission, and quality and cost of care.
International Journal of Quality in Healthcare, 22(6),
437–444.
Daley, G. M. (2010). A hybrid transitional care program.
Critical Pathways in Cardiology, 9, 231–234.
DRG Expert. (2012). A comprehensive guidebook to the
DRG classification system. OptumInsight. 28th ed.
Retrieved from www.shopingenix.com/ICD10
Ferrante, D., Varini, S., Macchia, A., Soifer, S., Badra, R.,
Nul, D., … Doval, H. (2010). Long-term results after a
telephone intervention in chronic heart failure. Journal
of the American College of Cardiology, 56, 372–378.
Gardetto, N., Greaney, K., Arai, L., Brenner, A., Carroll,
K., Howerton, N., … Maisel, A. (2008). Critical
pathway for the management of acute heart failure
at Veterans Affairs San Diego Healthcare system:
Transforming performance measures into cardiac
care. Critical Pathways in Cardiology: A Journal of
Evidence-Based Medicine, 7, 153–172. DOI:10.1097/
HPC.0B013e31818207e4
Garin, N., Carballo, S., Gerstel, E., Lerch, R., Meyer, P.,
Zare, M., … Perrier, A. (2012). Inclusion into a heart
failure critical pathway reduces the risk of death or
readmission after hospital discharge. European Jour-
nal of Medicine, 10(4), 760–764. doi:10.1016/j.
ejim.2012.06.006
Hospital Corporation of America. (2013). Tulane medical
center length of stay and 30 day readmission rate data
from January 1, 2012–May 31, 2013. New Orleans,
LA: Author.
Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A.
M., Francis, G. S., Ganiats, T. G., ... C. Yancy. 2009
focused update: ACCF/AHA guidelines for the diagno-
sis and management of heart failure in adults: A report
of the American College of Cardiology Foundation/
American With the International Society for Heart
and Lung Transplantation. Circulation. doi: 10.1161/
CIRCULATIONAHA.109.192064
Manning, S. (2011). Bridging the gap between hospital
and home: A new model of care for reducing read-
mission rates in chronic heart failure. Journal of Car-
diovascular Nursing, 26, 368–376. DOI:10.1097/
JCN.0B013E318202B15C
Panella, M., Marchisio, S., Demarchi, M. L., Manzoli, L.,
& Di Stanislao, F. (2009). Reduced in-hospital mortal-
ity for heart failure with clinical pathways: The results
of a cluster randomized controlled trial. Qual Safe
Health Care, 18, 369–373.
Peters-Klimm, F., Campbell, S., Hermann, K., Kunz, C.U.,
Muller-Tasch, T., & Szecsenyi, J. (2010). Case man-
agement for patients with chronic systolic heart failure
in primary care: The HICMan exploratory random-
ized controlled trial. Retrieved from www.trialsjour-
nal.com/content/11/1/56
Shearer, N. B. C., Cisar, N., & Greenberg, E. A. (2007). A
telephone-delivered empowerment intervention with
patients diagnosed with heart failure. Heart and Lung,
36, 159–169.
Staples, P., & Earle, W. (2008). The nature of telephone nurs-
ing interventions in a heart failure clinic setting. Cana-
dian Journal of Cardiovascular Nursing, 18, 27–33.
U.S. Department of Health and Human Services. (2012).
Hospitals Compare. Retrieved from http://hospital
compare.hhs.gov/hospitalcompare.aspx#cmprTab = 3
&cmprID = 190176&stsltd = LA&loc = 70131&lat
= 29.8930637&lng = -89.915978 5&name =
Tulane%20Medical%20Center&AspxAutoDetectCo
okieSupport = 1
van de Klundert, J., Gorissen, P., & Zeemering, S. (2010).
Measuring clinical pathway adherence. Journal of
Biomedical Informatics, 43, 861–872. doi:10.1016/j.
jbi.2010.08.002
Wagner, K. (2012). Her order sets save memorial Herman
$14 million. Health Cost Containment. Retrieved
from www.hfma.org/hcc
Zaya, M., Phan, A., & Schwarz, E. R. (2012). The dilemma,
causes and approaches to avoid recurrent hospital
readmissions for patients with chronic heart failure.
Heart Failure Reviews, 17(3), 345–353.
Sabrina Marie White, DNP, MSN, APRN, ACNP-BC,
received her Doctorate in Nursing from the University of South Alabama.
Presently, she is a nurse practitioner in Heart Failure at East Jefferson
Medical Center in Metairie, LA. She has practiced as a Heart Failure/Heart
Transplant practitioner for 11 years and received the 2013 graduate
award for her work in heart failure from Preventive Cardiovascular
Nurses Association. She also worked as a faculty member, educating and
shaping the minds of aspiring nurses at Charity School of Nursing and
Louisiana State University in New Orleans, LA.
Alethea Hill, PhD, MSN, ANP-BC, is currently Assistant
Professor at the University of South Alabama (USA) College of Nursing

and an Adult Acute Care Nurse Practitioner in private practice. She
obtained her BSN and MSN degree in Nursing from the University of
South Alabama and received a PhD in Nursing from the University of
Alabama at Birmingham. Her dissertation focused on the associations
between perceived discrimination, allostatic load, and insulin resistance
in nondiabetic African American women of the Jackson Heart Study.
Dr. Hill’s interest includes the impact of cardiovascular risk factors on
health outcomes. She is also interested in the interconnectedness of
social/environmental determinants of health and health disparities on
cardiovascular health status.
APPENDIX
Callback Form Analysis
Category
Total Number in
Compliance
Total Number Not
in Compliance Compliance (%)
Patients with appointments within 1–2 weeks postdischarge 53 6 90%
Patients performing daily weights 44 15 75%
Patients who were able to state the names of their meds 54 4 93%
Patients who can state their diet and foods to avoid 92 3 95%
Patients who know the warning signs of HF 59 0 100%
Patients who were aware of their HF symptoms 59 0 100%
Patients who exercised and understood the importance 39 20 66%
Patients who received educational information while hospitalized 57 2 97%

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