Implementation of a Disease Management Program in Adult Heart Failure Patients

Implementation of a Disease Management Program in Adult Heart Failure Patients

Bibliography

Name: Chantel Charais

Rank: LCDR

Presenter/Poster: Poster

Year: 2019

Abstract

Description:

Preventing and decreasing admissions and subsequent readmissions for patients with heart failure is a significant challenge for hospitals and outpatient practitioners.  The heart failure disease management program was implemented at Naval Medical Center San Diego to improve care, reduce the healthcare burden, and improve clinical outcomes, patient satisfaction, and quality of life in the patient population.

Objectives:

The objective of the heart failure disease management program was to utilize evidence-based practices to improve the quality of care for patients with heart failure through improved self-care education, increased follow-up, and reduction in 30-day readmission rates. 

Background: Approximately 5.7 million people in the United States are diagnosed with heart failure with projected prevalence rates to increase 46 percent by 2030.  Many heart failure admissions are preventable as acute exacerbations often result from a lack of medication management, poor patient treatment plan adherence, and lack of appropriate follow-up within the healthcare system.  In 2017, the 30-day heart failure readmission rate at Naval Medical Center San Diego’s Cardiac Care Unit was 30 percent, 7 percent higher than the national rate.  The disease management program incorporates best practices identified by the American College of Cardiology Foundation and the American Heart Association in an attempt to reduce adverse outcomes related to hospital readmissions. 

Implementation:

In December 2018, a multidisciplinary disease management program was implemented at Naval Medical Center San Diego’s Cardiac Care Unit to include:  patient education utilizing the teach back method, multimodal medication reconciliation, telephone follow-up within 48 to 72 hours of discharge, and follow-up visit within seven to ten days of discharge.  Data will be collected and analyzed for 90 days and compared to retrospective data from 2017.

Findings:

Data collection is ongoing and anticipated to be completed by March 2019.

Implications

Heart failure leads hospital admissions in the United States for individuals age 65 years or older affecting a large portion of the military beneficiary population.  Implementing a successful disease management program will assist to increase the health and quality of life of those affected by the disease process and potentially reduce overall military healthcare costs.

4 keywords: Heart Failure Disease Management