Question

In a large teaching hospital, there is a high rate of readmission for patients with congestive heart failure (CHF) who are being treated at the facility. The chief nursing officer (CNO) wants to know the cause of the readmissions, as the rate at this facility is almost twice that of competing healthcare entities in the area. The CNO works with the nursing researchers at the university to address this situation.

The researchers begin to scour the electronic health records (EHRs) of more than 15,000 CHF hospitalizations in the past 4 years to determine the cause of the situation. As they begin to understand this dataset, they are able to build a data mining model using algorithms to discover patterns and relationships in the data. Based on the old data, they determine that the key factor for readmission was the length of time it took to follow up at home with discharged patients.

In response to this new knowledge, a program in which nurses contact patients with CHF the day after their discharge by phone was developed, and a home visit is scheduled for the second day postdischarge to ensure a smooth transition to home or an assisted living facility. This follow-up within the first 4 days of discharge has reduced readmissions by 40%. The model that was used with the old data is being applied to the new data.

1. Outline your home visit.(Vital signs, assessment, education)

2. What information would you provide to your patient?

3. Why have re-admissions been reduced by 40%?

Answer 1

Home visit planning and caring differ as per patient health conditions. It should include Assessment, medication followup, vital signs checking, health education, and nursing care, etc.
Information we have to give to the patient that includes education to the patient and family about patient disease condition, management, warning signs, preparation for the followup appointment with the doctor, social concern, safety precautions, emergency contact, etc.
the home visit is a traditional care model approach it prevents health complications and readmissions. coordination and continuity of care in-home visits prevent poor outcomes, reduce high risk, promote safety for the patient. Follow-up care after patient discharge through home visits reduces medical complications for the patient. It ensures their health conditions and make awareness with their signs and symptoms and adverse effects and help for managing their health condition, it reduces the multiple readmission when patient able to manage their health illness at home and also reduce their health care cost.