During exacerbations of Congestive Heart Failure (CHF), older patients may receive care in multiple settings; often resulting in fragmented care and poorly-executed care transitions. The negative consequences of fragmented care lead to duplication of services; inappropriate or conflicting discharge instructions, medication errors, patient/caregiver anxiety, and increased costs of care. In light of changes in Medicare reimbursement penalizing hospitals with above set limits for heart failure (HF) readmissions, models of care are being evaluated for their effectiveness in satisfying this change as well as reducing fragmented care in this population. This paper reviews the Transitional Care Model created by Dr. Mary Naylor at the University of Pennsylvania (Penn Nursing Science, 2013). This model in introduces a patient-centered interdisciplinary team intervention designed to improve transitions across care settings.
Congestive Heart Failure
Congestive heart failure (CHF) is a condition in which the heart is incapable of adequately pumping blood throughout the body or unable to stop blood from backing up into the lungs. The most common cause of CHF is hypertension, previous myocardial infarctions, disorders of the heart muscle or the valves of the heart, and chronic lung diseases such as asthma or emphysema. CHF is a common diagnosis for individuals sixty five years and older. With the growing population of baby boomers, the rate of CHF is predicted to nearly double over the next forty years and will be a drain on healthcare resources. Treatment costs are estimated around $20 to $40 billon, with $8 to $15 billion spent on hospitalization alone (Quaglietti, Edwin, Ackerman, & Froelihe...
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...he Medicare Fee for Service Program. New England Journal of Medicine, 360: 1418-1468.
Naylor, M. (2012). Transitional Care Model. Retrieved from http://www.fiercehealthcare.com/special-reports/transitional-care-model
Penn Nursing Science. (2013). Transitional Care Model-About TCM. Retrieved from http://www.transitonalcare.info/about.tcm
Quaglietti, S. E., Edwin, J., Ackerman, L., & Froeliher, V. (2000, November/December). Management of the Patient with Congestive Heart Failure Using Outpatient, Home and Palliative Care. Progress in Cardiovascular Diseases, 43(3), 259-274. Retrieved from www.cardiology.org/recentpapers/susiechf:pdf
Senthilraj, G., & Ganeshan, R. (2013). Effects of a Hospital Wide Quality Improvement (Doctoral dissertation, University of Connecticut). Retrieved from http://digitalcommons.uconn.edu/cgi/vecontent.cgi?article=1464&context=gs_thesis
Chronic heart failure is a life threating disease, like other chronic diseases such asthma and diabetes chronic heart failure is a condition that is with the patient for life. Chronic heart failure can be very serious and difficult to manage, symptoms of chronic heart failure can be controlled, avoiding unnecessary hospital visit and live a long, healthy life by working with their health care
Takeda A, Taylor SJC, Taylor RS, Khan F, Krum H, Underwood M. (2012). Clinical service organisation for heart failure (Review). Cochrane Database of Systematic Reviews. Issue 9. Art. No.: CD002752. DOI: 10.1002/14651858.CD002752.pub3.
The symptoms of heart failure can be treated in several ways depending on the severity of illness. In early stages, non-invasive strategies such as life style changes, including diet and exercise, are usually recommended (Dumitru, 2015). These non-pharmacologic therapies include dietary sodium and fluid restriction, physical activity as appropriate, and attention
Heart failure is a major clinical, social and economic problem in the United Kingdom according to the Department of Health [DH] (2013).The National Institute for Health and Clinical Excellence [NICE] (2010) reported that about 900,000 people suffer from heart failure in the United Kingdom. The National Institute for Cardiovascular Outcomes Research [NICOR] (2011) conducted a national audit which found that one in every 20 people over the age of 65 is diagnosed with heart failure which demonstrates that it mainly affects the elderly. As a leading cause of mortality, heart failure contributes to more than 6,000 deaths each year (NICOR, 2011). Newly diagnosed cases of heart failure have a 40% risk of dying within a year (NICOR, 2011). Despite advances in therapy, mortality is still high and only half of patients are alive five years after being diagnosed with heart failure (NICE, 2010).
Standardizing The Hospital Discharge Process for Patients with Heart Failure to Improve the Transition and Lower 30 day Readmission. http://www.cfmc.org/integratingcare/files/Remington%20Report%20Nov%202011%20Standardizing%20the%20Hospital%20Discharge.pdf
My clinical rotation for NURN 236 is unique in that all patients I care for at Union Memorial Hospital in Baltimore, Maryland have a diagnosis of heart failure (HF). HF occurs when the heart is unable to pump adequate blood supply, resulting in insufficient oxygen and nutrients to the tissues of the body (Smeltzer, Bare, Hinkle, and Cheever, 2012). Approximately 670,000 Americans are diagnosed with HF each year and is the most common hospital discharge diagnosis among the elderly (Simpson, 2014). Moreover, according to the Centers for Medicare and Medicaid Services (CMS), HF is the leading cause of 30-day hospital readmission followed by acute myocardial infarction (AMI) and pneumonia (medicare.gov|Hospital Compare, 2013). This information along with my weekly HF patient cohort prompted my curiosity regarding impacts of HF readmissions, factors of HF readmission, and to compare suggested evidence based practice with policies utilized at Union Memorial for reducing the 30-day readmission rate for HF.
Hypertension increases the risk of heart failure 2 to 3 fold. (He, et al, 2001) The American College of Cardiology (ACC) has identified 4 stages of heart failure. (Hunt, Abraham, Chin et al, 2009). Screening patients for heart failure is sometimes controversial. Health care administrators...
The best way to prevent heart failure is to minimize the risks that cause it and to control existing health problems that are related to the condition such as high blood pressure and diabetes. If a person does happen to have heart failure there are many medications and treatments that can help control the disease and help the patient continue to live as normal of a life as possible. After being discharged from the hospital Mr. Carver will have to be aware of his condition at all times and take the proper measures to keep himself healthy. He will have to make many life changes and continue to keep up on any appointments made to make sure his condition is under control. With the proper understanding and management of his disease, Mr. Carver will be in a good condition to resume his life as before.
... internal regulatory accreditation survey which was coordinated and conducted by the Allina regulatory leads from across the system. The surveys are designed to replicate an actual Joint Commission survey by incorporating the same patient tracer methodology utilized by TJC. Non-compliant internal findings were evaluated by responsible individuals and corrective actions were put in place to bring the requirements into compliance. The internal survey findings were entered into the ARAS tool and became helpful adjuncts during the preparation of the 2010 PPR. A dedicated heart failure disease specific certification team worked diligently throughout the year to prepare the organization for a 2011 TJC certification survey. The application for heart failure program certification survey was submitted to the TJC in December 2010 with an anticipated site visit in early 2011.”
Nembhard, I. M., Alexander, J. A., Hoff, T. J., & Ramanujam, R. (2009). Why Does the Quality of Health Care Continue to Lag? Insights from Management Research. Academy Of Management Perspectives, 23 (1), 24-42. doi: 10.5465/AMP.2009.37008001
Katzenstein, Larry, and Ileana L. Pinã. Living with Heart Disease: Everything You Need to Know to Safeguard Your Health and Take Control of Your Life. New York: AARP/Sterling Pub. Co, 2007. Print.
Crumbie, A. (2007) Caring for the patient with a cardiovascular disorder In: Wash, M. & Crumbie, A. Watson’s Clinical Nursing and Related Sciences. 7th Ed. Bailliere Tindall Elsevier. London pg 244 – 324.
... patients with heart failure: Impact on patients. American Journal of Critical Care, 20(6), 431-442.
The Dutch Heart Failure Knowledge Scale is the tool that will be utilized to assess knowledge retention. It is a 15-item questionnaire that can be self-administered. T...
Nguyen, N. (2009, August). Improving quality and value in the u.s. health care system. Retrieved from http://www.brookings.edu/research/reports/2009/08/21-bpc-qualityreport