CHF Education March Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN

Transcription

1 CHF Education March 2015 Courtney Reaves, BSN, RN-BC Amy Taylor, BSN, RN Corey Paris, BSN, RN, CCRN

2 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

3 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

4 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

5 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 %, Dec % 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%,

6 WFBH CHF Core Measure Site Please view ore-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

7 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

8 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)

9 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

10 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

11 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.

12 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..

13 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

14 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.

15 TUG and Egress Documentation

16 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.

17 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.

18 Key Learner Documentation 2 3 1

19 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.

20 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?

21 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?

22 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?

23 WH IP Congestive Heart Failure Patient Education Documentation Be careful to select WH IP CHF and Individualize to Patient specific needs

24 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)

25 CHF Care Plan Documentation Type CHF and Individualize to Patient specific needs Remember don t forget Cognitive, Fluid Volume, and Health Behavior

26 79YO Female Lives Alone Case Scenario 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

27 Case Scenario: Care Plan How would you individualize this patients Care Plan? Do not select All

28 Case Scenario: Care Plan How would you individualize this patients Care Plan? Do not select All

29 Case Scenario: Care Plan How would you individualize this patients Care Plan?

30 Case Scenario: Care Plan How would you individualize this patients Care Plan?

31 Case Scenario: Care Plan How would you individualize this patients Care Plan?

32 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.

33 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 Discharge

34 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.

35 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.

36 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 hours of discharge.

37 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