When we’re hospitalized for a condition, no matter how mild or severe, we receive the best care and treatment from nurses, physicians, and many others during our hospital stay—until we go home.
For some of us, the transition is simple. We take it slowly—one day at a time—monitor our progress, stick to our medication schedule, and eventually begin to feel normal again. We heal, make a follow-up visit, if necessary, and go back to our lives.
But for some people, especially those living with congestive heart failure, the journey home is not as simple. Those people, unfortunately, often get readmitted to the hospital.
How Washington Health System reduced hospital readmission rates
Washington Health System, which operates three hospitals that serve Pennsylvanians in Washington and Greene counties, sought to lower its hospital readmission rates.
After reviewing its data, the health system found its highest population for readmissions was its congestive heart failure (CHF) patients.
In August 2016, Washington Health launched a pilot of the Ambulatory Heart Failure Pathway program, an initiative that gives patients a resource person to bridge the gap in care.
The program established heart failure navigators (HFNs), nurses who are available for outpatient follow-up care.
Healthy Me PA spoke with the program’s two HFNs, Shelly Sargent and Jennifer Sworden, to learn how the work they do impacts CHF patients’ long-term care.
What is the role of a heart failure navigator?
As navigators, Sargent and Sworden educate CHF patients before they leave the hospital on self-management tips, signs and symptoms and when to report them, and how to contact them if they need assistance.
Outside of the hospital, the navigators stay in contact via telephone and limited in-person interactions.
For instance, Sargent said, when a patient calls and reports symptoms, the standard protocol is to increase the dose of the medication and follow up. If the patient doesn’t respond to the increased dosage, the next step would be a treatment center.
The goal is to provide treatment without readmitting patients to the hospital.
According to Sworden, the program “improves the quality of life for patients” and “allows them to stay healthy and at home.”
“We’re one of the small community hospitals in the area, so we want to make sure we take care of the individuals as a whole, not just those in the hospital,” Sargent said.
Since the start of the program, Washington Health has enrolled more than 830 patients. The program receives referrals through other patients, as well as through primary care physicians.
According to Sworden and Sargent, the patients enjoy the personal touch to care because they build relationships with them. Oftentimes, patients feel comfortable enough to call for other needs, and will be honest with them about taking their medications.
“The patients like the fact that they call and don’t have to wait for someone to call back. They’re getting immediate attention, and they love it,” Sargent said.
Sworden and Sargent also enjoy the connection they make with their patients.
“We probably spend more time with patients now than bedside,” Sargent said.
“We get to know the patients and their families, what they like to do at home … dog’s names … grandchildren, too,” Sworden said.
For more information on the Ambulatory Heart Failure Pathway program, visit https://www.washingtonhospital.org.