Patients with heart failure need to do very specific things to keep their
conditions under control. They also need to learn how to recognize particular
signs and symptoms that indicate that a flare-up is imminent, and get
attention as soon as possible. Otherwise, says Certified Nurse Practitioner
Kathy Troupe, their conditions spiral out of control very quickly.
A particularly dangerous time for those with chronic diseases is immediately
following discharge from the hospital after a flare-up. New routines and
medications can result in another crisis, sending the patient back to
the hospital within weeks—even days. That’s why it’s
critical for recently discharged patients to be seen by their primary
care providers within several days of leaving the hospital.
For many years, the vast majority of critically ill patients were ending
up back in the hospital after discharge—sometimes multiple times.
A close look at possible causes indicated that these readmitted patients
did not have appropriate follow-up care. In the absence of a primary care
physician, these patients were going back into crisis—almost immediately.
In 2011, FMH started a program designed to bridge these gaps in care. Staffed
by a nurse practitioner, nurses, social workers, pharmacists, CNAs and
a care coordinator, the program set a goal to see discharged patients
without traditional follow-up care within three days of discharge. After
noting a marked reduction in readmissions, the hospital expanded the program
from just heart failure patients to any patient with a chronic disease.
And the results continue to be worth noting.
At FMH, the CARE clinic is helping to reduce the 30-day readmission rate
in high-risk patients significantly. It is proving to be especially effective
in addressing the health care needs of low-income seniors with complex
medical and social needs. All indications are that this type of follow-up
care is continuing to help patients get, and stay on, the road to recovery—and
out of the hospital—in ever-increasing numbers.
“Seeing patients outside of the Emergency Room environment makes
all the difference,” says CRNP Troupe, Clinical Director of the
FMH C.A.R.E. Clinic. “We are able to get to a diagnosis, figure
out a plan of care, and address any issues that might get in the way of
patients’ complete recovery. That’s what we’re here
for—to help put all the pieces of the puzzle together.”