Duke HF - Heart Failure Transitional Care

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Duke Heart

Stephanie Barnes, NP Duke University

Health & Medicine

Heart Failure Transitional Care
Stephanie Barnes, MSN, AGNP-C, CHFN
Duke Heart Failure Symposium
May 4th, 2024

Objectives
1. Discuss transitional care programs in the
US and prominent factors impacting
transitional care for the HF population.
2. Discuss evidence-based strategies to
improve HF care transitions.

Multiple Factors Impact Quality of Care Transitions
in Chronic HF
• Healthcare Provider Communication
• Follow-up Appointment/Care
Coordination
• Medication Management
• Self-Care/Symptom Management

Transitional Care Challenges: Health
Related Social Needs
• Access to Transportation
• Difficulty paying for prescriptions or medical bills
• Education and literacy
• Food insecurity
• Digital health
In order to address we must assess!

Fraser, M., Barnes, S. G., Barsness, C., Beavers, C., Bither, C. J., Boettger, S., Hallman, C., Keleman, A., Leckliter, L., McIlvennan, C. K., Ozemek, C., Patel, A., Pierson, N.
W., Shakowski, C., Thomas, S. C., Whitmire, T., & Anderson, K. M. (2024). Nursing care of the patient hospitalized with heart failure: A scientific statement from the American
Association of Heart Failure Nurses. Heart & Lung, 64, e1–e16. https://doi.org/10.1016/j.hrtlng.2024.01.007

Transitional Care: Education
• Understanding available resources during
and post-hospitalization
• Available education: Healthwise
Knowledgebase

When does HF Education Occur?
– Inpatient
– Discharge
• Heart Failure Zones
• Daily Weights/Scale Assessment and Distribution
• Heart Failure Action Plan
– Transitional Care Telephone Call

Transitions: Post-Discharge Workflow
• Telephone call (Heart Center RN)
• HF follow up w/in 7 days
• EPIC-HF automatically sent if portal use or
email on file
• Enrollment with population health/Duke
Well for eligible patients

Assessing Clinical Performance and
Quality
• Transitional Care/QI Programs
• Performance/Quality Measures
– New ACC/AHA HF Performance and Quality
Measures Released - American College of Cardiology
– CMS
• American Heart Association Get with the
Guidelines-Heart Failure Registry

Patients and their families are given a multitude of information about their health and commonly must make important decisions from these facts. Obstacles that prevent easy delivery of health care information include literacy, culture, language, and physiological barriers. It is up to the nurse to assess and evaluate the patient's learning needs and readiness to learn because everyone learns differently.

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Overview Write a 3-4 page evidence-based health care delivery plan for one component of a heart failure clinic. Nursing within an organization is a critical component of health care delivery and is an essential ingredient in patient outcomes (Kelly & Tazbir, 2014). The concern for quality care that flows from evidence-based practice generates a desired outcome. Without these factors, a nurse cannot be an effective leader. It is important to lead not only from this position but from knowledge and expertise. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: •Competency 2: Explain the accountability of the nurse leader for decisions that affect health care delivery and patient outcomes. ◦Describe accountability tools and procedures used to measure effectiveness. •Competency 3: Apply management strategies and best practices for health care finance, human resources, and materials allocation decisions to improve health care delivery and patient outcomes. ◦Develop an evidence-based plan for health care delivery. •Competency 4: Apply professional standards of moral, ethical, and legal conduct in professional practice. ◦Apply professional and legal standards in support of a care plan. •Competency 5: Communicate in manner that is consistent with the expectations of a nursing professional. ◦Write content clearly and logically, with correct use of grammar, punctuation, and mechanics. ◦Correctly format citations and references using current APA style. Reference Kelly, P., & Tazbir, J. (2014). Essentials of nursing leadership and management (3rd ed.). Clifton Park, NY: Delmar. Context In an effort to improve the patients' health literacy concerning heart failure, it is important that the clinic staff and the hospital staff present a consistent, evidence-based message on self-care to these patients and their families in order to decrease acute exacerbation and re-admissions. Review current evidence for clinical practice guides or protocols when developing your patient teaching plans and materials. Consider the following: •What does the patient know about the disease process as a baseline? •What does the patient need to do understand as far as the best self-care processes? •Can the patient identify proper medication compliance? •Is there a financial issue that affects compliance? •Who buys and prepares the food in the home? •Can the patient verbalize when to seek medical assistance? Questions to Consider To deepen your understanding, you are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. •What factors contribute to inadequate quality of care? •How effective are organizational mandates for quality? •How do financial concerns impact health and safety goals? Suggested Resources The following optional resources are provided to support you in complet.

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Duke HF - Heart Failure Transitional Care

1. Heart Failure Transitional Care Stephanie Barnes, MSN, AGNP-C, CHFN Duke Heart Failure Symposium May 4th, 2024

2. I do not have any disclosures

3. Objectives 1. Discuss transitional care programs in the US and prominent factors impacting transitional care for the HF population. 2. Discuss evidence-based strategies to improve HF care transitions.

4. What is it and why is it important?

5. Multiple Factors Impact Quality of Care Transitions in Chronic HF • Healthcare Provider Communication • Follow-up Appointment/Care Coordination • Medication Management • Self-Care/Symptom Management

6. Transitional Care Challenges: Health Related Social Needs • Access to Transportation • Difficulty paying for prescriptions or medical bills • Education and literacy • Food insecurity • Digital health In order to address we must assess!

7. Fraser, M., Barnes, S. G., Barsness, C., Beavers, C., Bither, C. J., Boettger, S., Hallman, C., Keleman, A., Leckliter, L., McIlvennan, C. K., Ozemek, C., Patel, A., Pierson, N. W., Shakowski, C., Thomas, S. C., Whitmire, T., & Anderson, K. M. (2024). Nursing care of the patient hospitalized with heart failure: A scientific statement from the American Association of Heart Failure Nurses. Heart & Lung, 64, e1–e16. https://doi.org/10.1016/j.hrtlng.2024.01.007

8. Transitional Care: Education • Understanding available resources during and post-hospitalization • Available education: Healthwise Knowledgebase

9. When does HF Education Occur? – Inpatient – Discharge • Heart Failure Zones • Daily Weights/Scale Assessment and Distribution • Heart Failure Action Plan – Transitional Care Telephone Call

10. Implementation of EPIC-HF

11.

12. Transitions: Post-Discharge Workflow • Telephone call (Heart Center RN) • HF follow up w/in 7 days • EPIC-HF automatically sent if portal use or email on file • Enrollment with population health/Duke Well for eligible patients

13. Assessing Clinical Performance and Quality • Transitional Care/QI Programs • Performance/Quality Measures – New ACC/AHA HF Performance and Quality Measures Released - American College of Cardiology – CMS • American Heart Association Get with the Guidelines-Heart Failure Registry

Editor's Notes

Transitional care for the heart failure population refers to the specific individual or programmatic interventions that designed to improve the shifts from hospital. Most of these shifts occur from hospital to home but can also be between healthcare facilitities. Heart failure with increasing prevalence, costs to the healthcare system, are a focus of transitional care work for most hospitals. Transitional care requires both communication and care coordination for success.

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