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Kaiser Permanente Colorado and VNA-Denver jointly offer intense, consistent education to elderly heart failure patients who are discharged from the hospital in need of home-based skilled nursing care. Kaiser clinicians refer such patients to VNA, which sends a home health nurse within 48 hours of discharge to perform medication reconciliation and initiate specific, congestive heart failure–focused, self-management education. The nurse visits approximately five to seven additional times to offer education based on a standard guideline that emphasizes goal setting, symptom identification, and specific self-management skills.

The VNA nurses give Kaiser care coordinators regular updates and notify them of any signs of an exacerbation, allowing physicians to intervene on a timely basis as needed. The program contributed to a 24-percent decline in readmissions and has improved patient knowledge and promoted good self-management behaviors. The program serves elderly, home-bound heart failure patients discharged from the hospital with a need for skilled nursing services.

“The pilot involved several plan-do-study-act (PDSA) cycles that led to a number of refinements.”

The impetus for this program came from the realization that heart failure patients who left the hospital in need of home health services were more likely to be readmitted than those not requiring such services. VNA nurses provided inconsistent self-management education to these patients, suggesting the potential to reduce readmissions through more intense, consistent education and better communication and coordination between the nurses and Kaiser providers.

Heart Failure in the United States

  • About 5.3 million people in the United States have heart failure.
  • One in 9 deaths in 2009 included heart failure as contributing cause.
  • About half of people who develop heart failure die within 5 years of diagnosis.
  • Heart failure costs the nation an estimated $32 billion each year. This total includes the cost of health care services, medications to treat heart failure, and missed days of work.

Heart Failure Death Rates, 2007-2009 – Adults Ages 35+ (by County)

Heart Failure Death Rates 2007 2009

Key program elements include the following:

Patient identification: Kaiser physicians and hospital-based care managers make a notation in the electronic medical record (EMR) of any heart failure patient who requires home-based skilled nursing care after discharge. This notation automatically generates an e-mail referral to VNA. In addition, VNA home health nurses sometimes identify patients with another condition who also require heart failure education.

Initial nurse visit: A VNA home health nurse visits the pa­tient at home within 48 hours of discharge. The nurse provides medication reconciliation, reviews any educational materials on heart failure provided at the hospital, and helps the patient identify goals related to his or her care. The nurse also provides the patient a sheet that lists specific symptoms (e.g., shortness of breath, weight gain, swelling), along with a color-coded se­verity classification system. Green indicates no such symptoms, yellow indicates symptom elevation and a need to call the primary care physician, and red indicates the need to go to the emer­gency department. The nurse also notes whether the patient has a scale and/or a blood pressure cuff and arranges for the patient to receive such equipment as necessary.

Ongoing home visits based on guideline:

Over the next 4 to 7 weeks, the VNA nurse visits the patient approximately 5 to 7 times, providing education based on a standard guideline that directs the nurses about the content and sequence of topics that should be taught during the visit, as outlined below:

  • Education on relevant topics: The nurse gives patients a book covering various topics related to management of heart failure, including vital signs, the signs and symptoms of an ex­acerbation, the importance of taking and recording daily weight and blood pressure, appropriate nutrition while on a low-sodium diet, and reading food labels. As necessary, VNA nurses use a booklet specifically written for those with low literacy; see the Tools section for more details. Nurses review each section of the book with patients, employing the “teach-back” method to ensure that they understand the material.
  • Goal setting: The nurse helps the patient set goals related to self-management and list potential barriers to achieving them, recording the information on a form that is reevaluated at each subsequent visit.
  • Daily health log and diet/fluid diary: The VNA nurse pro­vides the patient with a daily health log and teaches the patient to record daily weight, blood pressure, and symptoms. The nurse also provides a diet and fluid diary so that patients can track their food and liquid intake. These data are also re­viewed at each visit.
  • As-needed medical interventions: Depending on patient needs, nurses may provide medical interventions, such as wound care and help in managing intravenous equipment.
  • Cross-provider communication: Whenever a patient is as­signed to a VNA nurse, the nurse receives the name of the Kaiser chronic care coordinator (a registered nurse) at the pa­tient’s primary care clinic. The VNA nurse telephones the Kaiser Permanente coordinator right after the assignment to discuss the patient and then provides the coordinator with regular up­dates (usually weekly), along with notifications whenever con­cerns arise. The coordinator documents these conversations in Kaiser’s EMR and discusses any changes in health status with the patient’s physician. The two organizations are currently de­veloping a system to allow electronic communication between the VNA nurse and Kaiser’s care coordinator.

Problem Addressed

A chronic, life-threatening condition (particularly among the elderly), heart failure causes a significant clinical and economic burden. Patients frequently experience acute exacerbations that require inpatient care, many of which can be avoided if patients know how to manage their conditions and recognize and act on the early symptoms of an exacerbation.

  • Significant clinical and economic burden: Ap­prox­i­mate­ly 5.3 million people in the United States have heart failure, with 660,000 new cases diagnosed each year. Heart failure is responsible for between 12 million and 15 million office visits and 6.5 million hospital days each year; in 2006, the annual costs of the disease totaled roughly $29.6 billion.
  • Many avoidable readmissions: Almost one-third of heart failure patients are readmitted to the hospital within 30 days of their previous discharge. At Kaiser Permanente Colorado and elsewhere, discharged patients in need of home health nursing services are at particularly high risk of readmission. Many readmissions can be avoided if patients know how to manage their conditions and recognize and act on the early signs of an exacerbation.
  • Inadequate education: Home health services often do not adequately meet the educational needs of high-risk patients. For example, before implementation of this program, home health providers at the Visiting Nurse Association (VNA) in Denver provided education based on their own clinical knowledge, lead­ing to high variability across patients and many unmet educational needs. Standard guidelines to promote comprehensive heart failure education exist, but few home health providers employ them.


The program has improved patient knowledge and promoted good self-management behaviors, contributing to a 24-percent decline in readmissions.

  • Improved patient knowledge: During the 18-month study period, patients demonstrated improved knowledge of various important components of heart failure care, including use of med­ications, understanding the importance of measuring weight and blood pressure daily and following a low-sodium diet, and recognizing signs and symptoms that require immediate medical attention.
  • Good self-management behaviors: In a telephone survey administered 30 days after completing the program, patients re­ported employing good self-management behaviors, as outlined below:
  • Weight and blood pressure measurement: Almost all participants reported having a scale or blood pressure cuff, with 96 percent having a blood pressure cuff and 81 percent having both. (Those without such equipment generally lived in assisted living or other facilities in which staff regularly monitor their weight and blood pressure.) The vast majority of patients (84 per­cent) reported taking their blood pressure and recording their weight each day.
  • Medication and dietary adherence: Most participants (87 percent) reported understanding the purpose of their medications and how to take them. A similar percentage reported be­ing able to find dietary information about sodium on food labels and understanding the health implications of going over the rec­ommended sodium limit.
  • Fewer readmissions: In the first 18 months of the program, all-cause readmissions within 30 days of discharge fell by 24 percent among participants.

Planning and Development of Joint Processes

Selected steps included the following:

  • Presenting idea to heart failure committee: Program de­velopers presented the concept to Kaiser’s Heart Failure Gov­ernance Group, which develops and reviews initiatives related to improving heart failure care.
  • Enhancing education program: Nurses at VNA conducted a literature search to identify best practices in adult learning and heart failure education. The nurses used the information to develop the curriculum for the in-home educational sessions.
  • Forming work group: Program developers formed a work group composed of key stakeholders and operational leaders from both organizations. Key stakeholders included the program leaders at VNA-Denver and Kaiser Permanente, the VNA-Denver nurse specialist, and a Kaiser Permanente chronic care coordinator (registered nurse). This group reviewed the educational content and developed processes for enhancing work flow and communications between home health nurses and Kaiser providers.
  • Initiating pilot project: The group initiated a pilot project, with participating patients receiving standardized education and the VNA nurses and Kaiser care coordinators using the designed processes to communicate. The pilot involved several plan-do-study-act (PDSA) cycles that led to a number of refinements. Since spring 2010, the program has generally remained the same, although program developers continue to discuss and implement improvements as they see fit.
  • Training nurses: A clinical nurse specialist from VNA trained the association’s nurses on the educational program. The initial training covered heart failure in general, followed by training on the use of the heart failure guideline in the EHR. Each nurse was given a notebook with copies of all the patient handouts as well. Training is ongoing and includes detailed information regarding heart failure and guidelines for care, as well as open discussions with the nurses about what works and what does not. Newly hired nurses receive the same training as part of their orientation, and nurses receive additional training and attend information exchange sessions on the program each year.
  • Quarterly meetings: Program administrators from both organizations (the clinical nurse specialist, financial officer, and nursing director from the VNA and the project manager, care coordinators, and home health liaison services director from Kaiser) hold quarterly face-to-face meetings to review individual cases, with an eye toward ongoing improvement of communications and outcomes. These meetings were held more frequently (monthly) during the first 2.5 years of the program but tapered off once readmission rates stabilized.

Resources Used and Skills Needed

  • Staffing: Neither organization added staff for the program, as participating patients already received home-based skilled nursing care. The program has added approximately four visits to each participant’s typical home care services, with the additional visits being absorbed by existing VNA staff. Program de­velopers’ experience indicates seven visits on average are sufficient to help the patients begin to make lifestyle changes and manage their care; because the visits are more focused and consistent, patients receive the right level of care in the right venue, and neither organization has had to add staff or other resources to accomplish this.
  • Costs: The program required no incremental financial out­lays, as both organizations absorbed the additional workload as­sociated with the administrative management of the program. Work group participants, program directors, and the project man­ager each spend roughly 2 hours a month on program-related activities.

Getting Started with This Innovation

  • Involve stakeholders from all settings: High-quality care depends on good coordination across staff in various settings. To that end, involve relevant stakeholders in planning and de­veloping the program, based on the specific goals for the initiative (e.g., reducing readmissions). Possible stakeholders in­clude the primary care team, nurse care coordinators, case managers, hospital discharge planners, cardiology representatives, and representatives from venue management (e.g., skilled nursing, home health, hospital transitions, palliative care/hospice, outpatient primary and specialty care).
  • Emphasize common mission: To promote collaboration, focus on the needs of the patient rather than the business objectives of each participating organization.
  • Train field nurses: Because heart failure is a complex condition, field nurses must be knowledgeable about medications, dietary requirements, and other self-management issues.
  • Use pilot test to refine program: Consider testing on a small scale to identify opportunities to improve the approach, ideally using PDSA cycles. Program developers at Kaiser Per­manente and VNA initially discovered several work-flow and communications glitches that did not surface during the planning phase but became apparent after testing the program on the first few participants.

Sustaining This Innovation

  • Regularly monitor and discuss data on program’s impact: Program developers continue to meet quarterly to review data on the program’s impact and to discuss communications and other issues.
  • Regularly engage field nurses: Program developers hold periodic training and information exchange sessions to keep the field nurses engaged in the program.
  • Provide face time: Find opportunities for field nurses and the care coordinators to meet in person, as such meetings help to build and maintain trusting relationships among individuals who work in different organizations.
    Refine communications: Periodically review communication processes and consider how they can be improved. Success depends in part on understanding the possibilities and limitations of each organization’s electronic systems.

Kaiser Permanente Colorado Region is a not-for-profit, integrated delivery system operated by Kaiser Foundation Health Plan of Colorado and the Colorado Permanente Medical Group. The organization owns and operates 19 medical offices and 3 behavioral health and chemical dependency offices throughout the Denver/Boulder area. Group physicians provide care to 533,000 members in the 6-county metropolitan area and in Southern Colorado, including roughly 5,500 individuals in the Denver/Boulder area with heart failure. VNA of Denver serves more than 10,000 elderly patients in 17 Colorado counties. In 2010, nurses made 185,169 home visits, with the typical client being 75 years of age.

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