While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
Hiring a Nurse Care Advocate to Coordinate Heart Failure Care
Since implementing the position of Care Advocate, Marymount has steadily maintained 100 percent compliance with core measures for heart failure care. The team also reduced its heart failure readmission rate by 26 percent.
12300 McCracken Road
Garfield Heights, OH 44125
Marymount Hospital is a 320 bed, non-teaching hospital that is part of the Cleveland Clinic Health System.
Marcia Grenig, RN, BSN, MBA, CPHQ
Director of Quality
Coordinating heart failure (HF) care for discharged patients is a complicated but critical endeavor for all health care institutions and providers. It requires ensuring that patients receive the right information at discharge, the right caregiver support at home and follow-up inquiries to monitor progress. Failure to do this can lead to unnecessary readmissions or worse.
Wanting to ensure that every HF patient received the care needed to remain healthy and out of the hospital, the team at Marymount Hospital created the position of the Heart Failure Care Advocate. The care advocate serves as a liaison between HF patients, their physicians, family members, other caregivers and ancillary hospital departments that play a part in providing the needed HF care. Team members describe the care advocate as the “hub of the team wheel” that keeps the full HF continuum of care running smoothly.
The care advocate’s responsibilities include: ensuring that all heart failure patients receive complete discharge information like medication instructions, diet restrictions, etc.; making sure that a caregiver or care partner will be at home to assist the patient; and coordinating follow-up calls to check on patients within a few days after discharge. The care advocate also fills an important administrative role making sure that all the pertinent hospital information is recorded to show that core heart failure measures are being met.
Since implementation, the care advocate has also started to cultivate relationships with community partners that might be able to provide additional support to Marymount’s HF patients after discharge. These include the nursing homes which frequently discharged patient’s primary caregivers. Representatives from the nursing homes have shadowed the care advocate in her daily activities to learn more about the specific follow up care the patients’ need.
Poor care coordination contributes to the issue of avoidable readmissions.Learn more
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