Each year, nearly five million people living in the United States are hospitalized repeatedly for heart failure. In fact, the New England Journal of Medicine says it is the most common reason why people are readmitted to hospitals nationwide.
As Connecticut’s Quality Improvement Organization charged with the responsibility of protecting the rights of the state’s Medicare beneficiaries, we know that one out of five Medicare patients hospitalized for heart failure were readmitted to the hospital within 30 days of their discharge. Imagine the utter fear and frustration placed on patients, their families and their health care providers?
While this prevalent trend continues to threaten peoples’ lives as it burdens our health care system with excessive costs and inefficiencies, there’s a growing movement under way of 150 dedicated change agents; all of whom believe that many hospital readmissions for heart failure patients are preventable. These health care volunteers are determined to reverse this negative national trend, starting right here in Connecticut.
Convened by Qualidigm almost two years ago, these health care practitioners and providers formed into a dozen tightly-knit ‘Communities of Care’ spanning the state. They represent community hospitals, home health care and hospice agencies, nursing homes and specialty care practices. As a collective, they understand that many hospital readmissions could have been prevented with better coordination of care, transfer of information and education tools for physicians, as well as patients and their caretakers.
In routinely bringing such diverse health care professionals together to collaborate and share best practices, it was soon apparent that there was a huge gap in communications of health care information across the state’s health care continuum. To minimize the likelihood of a hospitalized patient with heart failure being unnecessary readmitted to an acute care hospital, Communities of Care have worked to standardize systems that include the critical information that should accompany every patient as they move from the hospital home, or to and from another health care setting. In other words, they are systematically looking for and filling in gaps in medical information and communications.
As an overall group, we were surprised to discover that there was not a readily available set of universal teaching materials and tools for health care practitioners, patients and their caregivers that highlight what heart failure is and how best to manage the chronic illness. Again, to shore up communication gaps and create essential educational tools, Qualidigm produced Heart Talk, a video series funded by the Centers for Medicare & Medicaid Services.
The goal of the short videos is to offer easy-to-understand and consistent information about heart failure at a sixth grade level. We identified that all too many patients did not even realize that they had heart failure for several years, because their doctor used terms they did not understand — ‘pulmonary edema,’ ‘fluid on the lungs,’ ‘congestive heart failure’ or ‘retention of fluid’ — to describe their chronic condition.
The free films are being used by hospitals, nursing homes, home care and hospice agencies, physician practices, patients and caregivers nationwide and are available online. They focus on the key recommendations that, if followed, can help patients with heart failure live healthier lives without unnecessary hospitalizations.
Stemming escalating health care costs remains a national priority. Communities of Care, while currently focused on patients with heart failure, is a harbinger of hope to prevent readmissions for patients with other diseases in Connecticut or elsewhere in the country.
We know that improved medical processes, transference of critical information and education can only lead to better health care outcomes, and that means happier patients and families and a health care system that is much more cost-effective.
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Anne Elwell, a registered nurse, is vice president of community relations at Qualidigm in Rocky Hill.
