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Team-based approach to manage heart failure can reduce readmissions


In a presentation at the 2015 AHA Fall Conference, Kim Newline, RN spoke on how healthcare providers, with various strengths, in and out of a hospital can help prevent unnecessary readmissions.

“A team of healthcare providers in and out of the hospital with varied strengths and experiences can be the difference between multiple readmissions and time in the hospital or a higher quality of life in the community for many patients [with heart failure],” said Kim Newlin, RN, a cardiovascular clinical nurse specialist/nurse practitioner for Sutter Roseville Medical Center, Roseville, California.

In her presentation at the American Heart Association (AHA) meeting entitled “Ideal Team Approach in Management of Chronic Heart Failure: It Takes a Village!”,  Newlin focused on the goal of reducing hospital readmissions in advocating team-based care for patients with heart failure.

Along with helping to ensure care coordination among providers and stimulating the development of integrated care systems, she said that focusing on readmissions is a precursor to bundled payments and shared risk models of reimbursement, and emphasized the importance of reducing readmissions given the high cost of hospitals.

Related:Preventing hospital readmissions

Regarding financial penalties that Medicare places on hospitals whose risk adjusted 30-day readmission rate for heart failure is higher than the national average, Newlin said that the importance of transitional team-based care is recognized by Medicare, which offers a higher reimbursement for transitional care offered by team members in the office (i.e., CPT codes 99495 and 99496). The team members that can comprise such transitional care include a nurse, social worker, and/or a pharmacist.

Based on the needs of the patient, potential members of a hospital-based multidisciplinary team may include nurses, physicians, physical therapists, pharmacists, respiratory therapists, social workers and case managers, palliative care and hospice, care transition coordinators and navigators, as well as skilled nursing liaisons.

Outpatient-based teams could include home health and hospice, as well as skilled nursing facilities that provide access to telemonitoring, allied health professionals, (physical therapists, nutritionists, and social workers), and advanced care planning among other services.

Citing components of discharge recommended by the Heart Failure Society of America, Newlin highlighted the importance of vigilant follow-up to optimize medical therapy, increase access to providers, detect early signs and symptoms of fluid overload, and assist with social and financial concerns.

“It is essential that patients are given an appointment within seven days after a hospitalization when the risk for adverse events is higher due to changes in medications, deconditioning during the stay, need for follow-up tests, and increased anxiety all increase the possibility that the patient will go back to the hospital, “she said.

For patients with advanced heart failure, she stressed the need for primary care physicians to find a heart failure team or clinical led by a cardiologist or nurse practitioner to provide consultation on potential therapies such as transplants and ventricular assist devices.

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