CHF Education March 2015 Courtney Reaves, BSN, RN-BC

Amy Taylor, BSN, RN

Corey Paris, BSN, RN, CCRN

Wake Forest Baptist Medical Center

Objectives

• To improve patient outcomes

• Decrease CHF readmissions

• Improve patient and family compliance

• Review the Transitional Care Initiative process

• Enhance nursing education related to the care of the CHF patient

Care of the Heart Failure Patient

• Initiatives to improve patient outcomes with Heart Failure at WFBMC

Transitional Care Services

Joint Commission HF Self Selected Measures

Current Process Improvements

Interdisciplinary Care Team approach

Focus on Patient Education and Care Plan Development

Discharge Planning

TCI (Transitional Care Initiative) • TCI (Transitional Care Initiative) formally known as

BOOST (Better Outcomes for Older Adults through Safe Transitions)

Program implemented to improve best practices

Inpatient discharge planning

Provider handoffs from hospital to home

Community resource connections

Wake Forest Baptist Medical Center

Current HF Joint Commission Self-Selected Measures

1. PNA vaccine: Goal 100%, 95% over the past 6 months

2. HF Readmission numbers:

• Last 3 months:

Sept. 17%, Oct. 16.50%, Dec. 17.14%

3. HF satisfaction: We have seen a drop in our scores

• Last 3 months:

Oct. 82.5%, Nov 90.62%, Dec. 66.7%

4. 7 day follow-up appointment scheduled: Goal 80%

• Average 59%,

Wake Forest Baptist Medical Center

WFBH CHF Core Measure Site • Please view

• http://intranet.wakehealth.edu/Departments/Nursing/Core-Measures/CHF-Core-Measures.htm

What will you find?

• Current HF clinical practice guidelines

• Core measure data

• Patient Satisfaction

• Contact information for Cardiac Wellness Educators

Wake Forest Baptist Medical Center

HF Patient Satisfaction

HF patient satisfaction is focused on 4 questions.

Ready for discharge

Informed about your medications at discharge

Instructions given related to care at home

Speed of the discharge process

Current Process Improvement

• Bedside rounding

• Discharge Checklist

• Interdisciplinary huddles

• DPS (Discharge Prescription program)

• Hospital to home HF clinic

• PCP coordinator

• Hospital wide readmission huddle

• Hospital wide safety huddle

• Transitional care services

• Resource program for supplying equipment (scales, BP machine and/or pillbox)

• Utilization of HF stoplight magnet

• Cardiac Wellness Educator (one on one HF teaching)

Major Nursing Roles

• Monitor response to treatment

• Provide Patient and Family Education

• Relay information to the multidisciplinary team during the huddles (Charge Nurse).

• HF patient added to WakeOne TCI system list(Cardiology units only)

• Assess patient’s mobility, add PT order’s if needed

• Activate HF care plan and document reflecting individual goals and plan

Wake Forest Baptist Medical Center

Interdisciplinary Involvement • Interdisciplinary Collaboration through daily “team”

huddles to discuss plan for the day and plan for the stay

• Can this HF patient be referred to possible Transitional care services after discharge to help prevent readmission

• Who does the team consist of?

PT/OT

Care coordination

Nursing

Physicians

Pharmacy

Wake Forest Baptist Medical Center

How do you know if your patient needs PT?

• There are two bedside evaluations that can be performed by the RN to evaluate the patient's need for PT orders.

TUG Assessment

Egress Test

• The RN can choose which evaluation they would like to use, complete with the patient, document the outcome, and enter PT orders as needed.

• Documentation can be noted in daily cares/safety in TUG assessment. If Egress was performed type result in comments.

Wake Forest Baptist Medical Center

TUG Assessment

• Patients wear their regular footwear and can use a walking aid if needed.

• Please stay with the patient during test for safety.

• An older adult who takes ≥ 14 seconds to complete TUG is at high risk for falling and needs PT.

.

Wake Forest Baptist Medical Center

TUG Instructions • Begin by having the patient sit back in a standard arm

chair and create a line 3 meters or 10 feet on the floor

• Observe the patient’s postural stability, gait, stride length, and sway.

• Instructions to give the patient: When I say “Go,” I want you to:

Stand up from the chair

Walk to the line on the floor at your normal pace

Turn

Walk back to the chair at your normal pace

Sit down

Wake Forest Baptist Medical Center

Egress Test Consists of 3 tests – Patient must perform all 3 to pass Egress Test

• Test 1

Three reps of sit-to-stand

• Test 2

Three steps of marching in place

• Test 3

While the patient is standing with both feet together the patient will be requested to advance one leg forward and then return it to the starting position. The task is repeated in the other leg.

Wake Forest Baptist Medical Center

TUG and Egress Documentation

Wake Forest Baptist Medical Center

Teach Back for Patient Education

• Studies show that 40-80% of the medical information patients receive is forgotten immediately and nearly half of the information, that is retained is INCORRECT.

• Teach back method is a way to confirm that the patient fully understands all teaching points by having the patient teach the information back to the nurse.

Wake Forest Baptist Medical Center

Identify the Key Learner

• Identify the key learner: Patient, family member, and/or friend/caregiver. This person will be mainly responsible for obtaining patient education from the RN.

• Document the key learner in the patient education area under the assessment tab.

• Add the WH IP congestive heart failure (aka CHF) option by clicking add title in the patient education section under the Unresolved education tab.

Wake Forest Baptist Medical Center

Key Learner Documentation

1

2

3

Wake Forest Baptist Medical Center

Teach Back

• Why we use teach back method • Ensure information is understood/integrated into

memory. • Check for lapses in communication • Promote a more effective two-way discourse between

clinicians and patients.

Wake Forest Baptist Medical Center

Learning Level 1

• Level 1-Knowledge (What?)

• What sort of things do you monitor at home for your CHF?

• What symptoms were you having that made you decide to come to the hospital?

• What is the average amount of liquids you drink everyday?

Wake Forest Baptist Medical Center

Learning Level 2

• Level 2-Attitudes (Why?)

• Why would you be worried if your legs and feet were swelling?

• Why is it important for you to monitor how much fluid you drink?

• Why are you suppose to weigh yourself at the same time everyday?

Wake Forest Baptist Medical Center

Learning Level 3

• Level 3-Behaviors (How?)

• How would you tell your son about your symptoms of heart failure?

• How do you plan to measure the amount of fluid you are drinking each day?

• How will you remember to weigh yourself everyday?

Wake Forest Baptist Medical Center

WH IP Congestive Heart Failure Patient Education Documentation

1

2

3

4

5 Be careful to select

WH IP CHF and Individualize to Patient

specific needs

Wake Forest Baptist Medical Center

CHF Care Plan

• When adding patient care plan be sure they are tailored to patients current needs

• Important Sections

• Cognitive

• Fluid Volume

• Health Behavior (Address Mobility with PT documentation)

Wake Forest Baptist Medical Center

CHF Care Plan Documentation

1

2

3 Type CHF and

Individualize to Patient specific needs

Remember don’t forget Cognitive, Fluid Volume, and Health

Behavior

Wake Forest Baptist Medical Center

Case Scenario • 79YO Female Lives Alone

History: CHF, DM, Current Smoker, Non-Compliance,

Admitted for increased weight gain (4lbs) and Shortness of breath and fatigue at rest.

During this admission

Started on an ACE inhibitor

Received IV diuretics

Wake Forest Baptist Medical Center

Case Scenario: Care Plan

• How would you individualize this patients Care Plan? Do not select All

Wake Forest Baptist Medical Center

Case Scenario: Care Plan

• How would you individualize this patients Care Plan? Do not select All

Wake Forest Baptist Medical Center

Case Scenario: Care Plan

• How would you individualize this patients Care Plan?

Wake Forest Baptist Medical Center

Case Scenario: Care Plan

• How would you individualize this patients Care Plan?

Wake Forest Baptist Medical Center

Case Scenario: Care Plan

• How would you individualize this patients Care Plan?

Wake Forest Baptist Medical Center

Care Plan Case Scenario cont.

• How would you individualize this patients Care Plan Shift and discharge Documentation

Utilize comments to individualize your plan of care.

Discharge • Closing the loop

• Pharmacy reconciliation

• Ability to fill prescriptions

• Physical Therapy clears the patient

• Care Coordination signs off

• AVS discharge checklist completed

• Goal Follow-up in 7 days of discharge

• Screen for the Pneumonia vaccine

Transitional Care Services 716-Join (5646)

Goal: Discuss in huddle our high risk patients and screen for patients that could benefit from the Transitional Care Services. Your case management team is a great resource.

• ED supportive care RN

Nurse, ED physicians, and Care Coordination assist with the transition of patients to Medicaid Care Management.

• Care Plus

Intensive primary care services by a multidisciplinary team to improve physical, mental, and functional health outcomes for high risk patients.

• Paired Health

A home visit by a physician or NP within 7-14 days of discharge to ensure a successful transition from hospitalization to PCP.

• WF Baptist Care at home

Home health care provided for patients discharging home with a skilled need

• SNF partnerships

Short-term rehab (<30 days) with a goal to transition to an ALF or residence.

Wake Forest Baptist Medical Center

•Faith Health

A partnership between faith communities, health systems, and others to improve health.

• Palliative care

Inpatient, outpatient clinic, and home visits by a physician or NP to assist patients with serious illnesses.

• Anchor Program

Program that offers home visits within 48-72 hours of discharge.

Wake Forest Baptist Medical Center

To document completion of this module in your continuing education record:

1) Click return to “Courses & Test”.

2) Click on . 3) Enter Test Code: HF2015