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.


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