Nurse-Led Clinics Battle Readmissions

Alexandra Wilson Pecci, for HealthLeaders Media , August 28, 2012

Hospitals and medical centers that make the investment in providing this kind of care also reap benefits down the road. I'm reminded of a hospital-to-home program at Mercy Health-Fairfield Hospital in Fairfield, Ohio, which assigns care transition coaches at discharge to patients who are at high risk for readmission.

A pilot version of the program decreased the readmission rate for the target population to 7.5%, which is about a third of the national rate. Mountain States Health Alliance leadership says the congestive heart failure clinic's goal for the first year is to reduce its total congestive heart failure readmissions by 5%.

In another program getting started in Idaho, nurse care coordinators will advocate for and provide health coaching to patients to help them manage their health conditions. Through the Healthy U CoPartner Program, a joint effort of Regence BlueShield of Idaho and St. Luke's Health System, Regence members who meet specific criteria and agree to enroll in the program will be assigned their own individual nurse care coordinators who will be part of their healthcare team. Coaches will help the patients develop personalized treatment plans, promote lifestyle adjustments, and act as a health coach.

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1 comments on "Nurse-Led Clinics Battle Readmissions"

Monica Rauton, DNP, ANP-BC (9/4/2012 at 2:14 PM)
As a recent graduate of the doctor of nursing practice program at Arizona State University, development and implementation of an outpatient heart failure clinic was what I focused on for my evidence based practice project. Our program is a multidisciplinary 6 week outpatient program that involves a cardilogy NP (myself), 2 certified HF nurses, a pharmacologist, a dietician and an exercise physiologist. Our setting is in cardiac rehab and we offer not only education, but weekly physical assessments and an exercise component. Our program has been very successful and has been effective in reducing readmission rates, improving quality of life and functional status for patients. Many more clinics such as these are needed and are actively being developed and implemented. This is refreshing as medicine is in dire need of a more preventative approach to patient care.




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