Coordinated Home Care Reduces Readmissions

    • February 15, 2013

Interview Title:
Hospital Partners With Local Home Health Agency to Improve Transition of Care for Heart Failure Patients

CMMC’s 30-day all cause heart failure readmission rate dropped from 22.8 percent to 17 percent.

Central Maine Medical Center
300 Main Street
Lewiston, ME 04240

Central Maine Medical Center (CMMC) is a 250-bed general hospital. CMMC’s Heart and Vascular Institute provides prevention, screening, treatment and rehabilitation services to patients with heart-related health concerns in inpatient and outpatient settings.

Susan Raye Horton, DNP, APRN, CHFN
Executive Director, Central Maine Heart and Vascular Institute
Phone: 207-753-3910

Innovation Implementation:
Recognizing that most of its readmissions among heart failure patients occurred within 10-14 days of discharge, Central Maine Medical Center (CMMC), forged a strategic partnership to ensure that heart failure patients follow their discharged instructions at home.

CMMC worked with Androscoggin Home Care & Hospice – the largest service of its kind in the community – to develop a nursing liaison support program.  Androscoggin nurses provided individualized home care visits to every CMMC heart failure patients within the first 1 to 3 days after they were discharged.

In addition to home visits, nurses used transtelephonic monitoring to detect abnormalities or other risk signs among heart failure patients. Transtelephonic devices transmit patient data through a phone line. CMMC created an electronic system so the data could be shared and recorded – and used to identify CMMC’s “at-risk” population.  Based on the home care assessment, CMMC was able to customize action steps and follow up for patients classified as at-risk for being readmitted. The use of this technology was especially helpful for patients that were immobile or unable to manage their condition independently.

CMMC reduced its heart failure readmissions from 22.8 percent to 17 percent within 18 months and staff credit much of its success with the collaboration of non-hospital community care. Building on this success, CMMC is currently in the process of creating an outpatient heart failure program for high risk heart failure patients.