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patients are being admitted for a same non heart failure diagnosis, in hospital and home education can be tailored to fit this need. The data from the chart audit can be compared to the readmission data collected after the program has been running for three months and again at six months.
PREVENTING HF READMISSIONS11A statistical analysis of the data will be completed to see if there was a reduction in the percentage of readmissions and if the reduction was large enough or significant to be credited to the new measures put in place. To assist in measuring the effectiveness of the new program a CHF Transitional Care Evaluation Tool will be used on all CHF patients. (See Appendix A) The tool will measure if appointments are made prior to discharge for one or both of the nurse home visits and also a follow up with the patients’ primary care doctor, which is a current Aurora practice. The tool also tracks if these appointments were executed and the nurse actually visited the home and the patient attended the primary care appointment. The tool will track if the patients had a rehospitalization within 30 days and at 60 days and track the readmitting diagnosis. The patients will be on a nine point scale, for each appointment schedule prior to hospital discharge they would get 1 point and for each post discharge appointment attended they would get 2 points. Measuring the scheduling of appointments will give an idea of how well executed the implementation of the CHF Transitional Care program was carried out and the tracking of attendance at appointments will show how well Aurora Health Care followed out the program. Although the goal is always to have 100% compliance it is known that not all patients will follow through and not all appointments can be prescheduled, this data will be able to show and compare patients in the same timeframe. The data willl also demonstrate how home visits reduced readmissions or show when readmissions occurred, where the breakdown occurred (prescheduling, no show not call, RN missed visit,). Education and activities done at the home care visits have a large impact on the outcome and effectiveness of the CHF Transitional Care Program. Home care nurses will be provided lists of topics to be covered at each visit. This will ensure patients are receiving the necessary information and that all patients are receiving the same information to make comparisons valid. The first visit will focus on understanding and reinforcement of education provided in the
PREVENTING HF READMISSIONS12hospital and how it can be successfully done in the home setting. Studies have shown that not factoring in the economic, social, and physical challenges patients face in the home setting in regards to CHF patients causes relapses and rehospitalizatons (Ruschel, Azzolin, & Rabelo, 2012 & Bathaei, Ashktorab, Ezati, & Majd, 2012).The nurse will be able to see the food actually in the patients home and discuss how to prepare it in a heart healthy manner and also provide resources if assistance is needed in getting food.