SPRINGFIELD – Prairie Heart Institute at St. John’s Hospital recently implemented a Hospital to Home (H2H) program in which all patients discharged with Congestive Heart Failure (CHF) or an Acute Myocardial Infarction (heart attack) are offered a follow-up visit with a registered nurse within one-to-two weeks after their hospitalization. The consultation with the nurse is in addition to follow-up appointments patients will have with their physician.

The goal of the Hospital to Home program is to improve the transition from inpatient to outpatient by providing patients with early follow up, counseling on medication adherence, and symptom recognition. During the visit, the discharge instructions are reviewed, social service referrals can be made if needed, and education is provided on diet, medication, and who to call if symptoms develop. The objective is to keep patients from being readmitted due to a lack of education, non-compliance, or access to follow-up or medication. 

“Since we started the Hospital to Home program six months ago, we’ve been able to help over a hundred cardiac patients better understand such things as their dietary restrictions, medication management and what symptoms require a call to their physician,” says Claire Call, RN, manager, Heart Failure Support Clinic at St. John’s. “Because many patients find it difficult to retain all the information they receive during their hospital stay, these clinics give us the opportunity to review that information and identify issues that prevent them from being successful at home due to taking medications incorrectly or struggling with dietary or social concerns.”

Research has shown that the failure to follow discharge care plans can often result in an increase in re-admissions. A recent study found that unplanned re-hospitalizations account for nearly 17 percent of Medicare funding for hospitals. Patients with CHF have higher 30 day readmission rates than patients who suffer from any other disease. 

From January to March of this year, St. John’s 30 day readmission rate for CHF was 13.1%, compared to a 22% average for large teaching hospitals across the U.S. during the same three months. In July, 2009 St. John’s was identified as the only Illinois hospital to have CHF readmission rates that were better than the national average. That report showed St. John’s 30 day readmission rate for CHF at 21.2% compared to the national rate of 24.5%.

“The Hospital to Home program is an example of grassroots efforts to reform health care here at the local level by developing more effective protocols for our patients,” adds Call. “In the first few months that we’ve started the program, we’ve seen our readmission rates for CHF decrease dramatically. While we’re proud of our progress in lowering readmission rates, we’re extremely pleased that these clinics are helping improve the lives of our patients.”

The concept for Hospital to Home clinics is cosponsored by the American College of Cardiology and the Institute for Healthcare Improvement. St. John’s clinics are held twice a week at Prairie Heart Institute and are staffed by cardiac rehab and heart failure nurse specialists. 

For more information about the clinics, please call 217-544 6464 x 67828