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Approximately 5 million people in the United States have heart failure, with 550,000 new cases diagnosed annually. The condition is the number one cause for hospitalization among the elderly; one fifth of all hospitalizations have a primary or secondary diagnosis of heart failure.

In response, magnet hospital Hackensack University Medical Center (HUMC) created a dedicated inpatient heart failure unit that is dramatically reducing readmission rates in this population. This special report, "Reducing Readmissions for Heart Failure Patients: A Multidisciplinary Approach for the Medicare Population," chronicles the evolution and operation of the unit and its foundation in continuous care and patient education and self-management.

Part of the Reducing Hospital Readmissions Toolkit, a four-volume set with case studies from a variety of programs aimed at reducing unnecessary hospital readmissions, from discharge planning, transition coaching, transitions in care case management, medication reconciliation, community partnerships, home visits, assessments to identify high-risk patients and patient and caregiver education. Click here to save 25% when you order the Reducing Hospital Readmissions Toolkit.

In Reducing Readmissions for Heart Failure Patients: A Multidisciplinary Approach for the Medicare Population a 23-page report, the team's education coordinator and administrative manager — both cardiac nurses — describe how the team is overcoming barriers to effective heart failure management.

Contributing presenters Michele Gilbert, education coordinator of the heart failure team, and Lenore Blank, administrative manager, share some of the workings of the team, including:

• Addressing comorbidities, medication reconciliation, diet, psychosocial concerns and financial and physical limitations often faced by heart failure patients;
• Applying continuous care strategies to improve the quality of emergency room, inpatient, outpatient and home care of heart failure patients;
• Fostering patient education and self-management through improved discharge instructions, home visits, telephone follow-up and support groups;
• Developing admission and exclusion criteria for the heart failure unit;
• Educating and training multidisciplinary team members;
• Building partnerships with other heart failure nurses and subacute facilities to improve care for heart failure patients;

The HUMC dedicated heart failure unit received a grant from Pursuing Perfection: Raising the Bar for Health Care Performance, a $21 million initiative sponsored by the Robert Wood Johnson Foundation (RWJF) and the Institute for Healthcare Improvement (IHI), an internationally recognized leader in healthcare quality.

This report is based on a 2007 audio conference on pursuing perfect care for the chronically ill by focusing on the whole patient.

Table of Contents

• Magnet Hospital Aims for Perfect Care of Heart Failure Patients
  • Barriers to Effective Heart Failure Management
  • Types of Heart Failure and Evolution of Treatments
  • Inpatient Care, Outpatient Management Affect Outcomes
• Creating a Dedicated Heart Failure Inpatient Unit
  • Effective Home and Subacute Care Reduces Readmissions
  • Multidisciplinary Heart Failure Team
  • Meeting Core and Quality Measures
  • Medication Reconciliation
• Q&A: Ask the Experts
  • How-to’s of Home Visits
  • Opening a Heart Failure Clinic
  • Daily BNP Notifications
  • Sharing Knowledge with Other Facilities
  • Strategies to Engage Physicians
  • Empowering the Primary Care Nurse
  • The Effect of Quality on Recruiting and Patient Admissions
• Glossary
• For More Information
• About the Presenters