Employing a multidisciplinary team-based approach to care for heart failure (HF) patients that includes the development and dissemination of patient-friendly, standardized educational materials can both streamline resources and decrease readmissions, according to a poster presented at this year’s annual leadership meeting of the American College of Cardiovascular Administrators (ACCA) in Chicago.

Kristin Dixon, RN, MSN, CSN, and Megan Mansfield, RN, BSN, of Scripps Health in San Diego, set out to understand whether a multidisciplinary approach to treating HF patients, including revamping tools and intervention, could reduce hospital readmissions.

Dixon and Mansfield specified three goals:

• Track, trend and influence quality measures including readmission rates;
• Create a standardized patient education booklet used from the outpatient and inpatient settings for Scripps HF patients; and
• Implement an individualized patient teaching method based on assessments to improve self care behaviors and prevent readmissions.

During the process, Scripps put together a team to streamline and align HF care, and also condensed six evidence-based HF resource packets into one branded HF booklet.

Lastly, the health system piloted the Advanced Practice Nurse (APN) intervention for high-risk HF patients. The APN intervention initiative included an individualized teaching approach to the patient based on assessment and followed up with these HF patients for four weeks via telephone.

Dixon and Mansfield reported that the updated HF patient resources are now distributed in outpatient, inpatient and the home health setting. Additionally, it was noted that within six months of implementation of the APN model, HF readmission rates dropped 11 percent, from 22 percent to 11 percent.

Dixon and Mansfield concluded that “multidisciplinary teams play an important role in managing chronic disease,” and “an APN-led intervention can significantly decrease readmissions.”