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It’s been more than two years since Ellamae Hendrix was hospitalized for her chronic heart failure. That’s “good news” says the vibrant 82-year-old patient, who receives the outpatient care at BWH that she needs to manage her disease and stay out of the hospital.
Heart failure, or problems with the pumping action of the heart, is the most common reason patients are readmitted to Partners hospitals. But the Partners Heart Failure Management Program is making strides in ensuring these patients get the outpatient services and education they need to prevent readmission.
“Our mission is not only to improve the quality of life of heart failure patients, but to keep them out of the hospital,” said Gilbert Mudge, MD, medical director of the Partners Heart Failure Management Program at BWH and Faulkner Hospital.
Evidence shows that proactive health care, education and outpatient services reduce hospital admissions for heart failure patients. To achieve its mission, the Heart Failure Management Program aims to identify the 2,600 heart failure patients discharged from Partners hospitals each year and connect them with appropriate outpatient follow up before they leave the hospital.
Program manager Matthew Quin, BSN, RN, stresses the importance of catching these patients prior to discharge. “Once a patient is discharged, it becomes significantly more difficult to identify them and connect them with the services they need to manage their care,” Quin said.
The team’s challenge is that patients with heart failure often are admitted to the hospital for other problems and are spread across many units.
That’s where Rebecca White, MS, comes in. As the heart failure referral coordinator for BWH, her job is to scan the list of inpatients each morning, pull the medical charts of those who might have heart failure and speak to their physicians.
“I look for patients with a current diagnosis of heart failure and those who have been admitted for heart failure in the last two years,” White said.
Among the services available to appropriate patients are a telephone health coach program, a telemonitoring program through Partners Home Care or follow up with heart failure nurse practitioner Norma Osborn, NP.
“Those who need routine, but intensive outpatient care come to me,” Osborn said.
She collaborates with her patients’ primary care providers and general cardiologists to manage heart failure for patients newly diagnosed with the disease, those who have had multiple heart failure-related admissions and those who need intensive monitoring or adjustments in medication dosage.
Part of her job is to teach patients to give their hearts the best care. “Self care requires following a low-salt diet, limiting fluid intake and taking medications such as diuretics, beta blockers and ACE inhibitors,” Osborn said.
She educates patients to watch for signs that indicate an increase in fluid, which increases the workload of the heart. Hendrix, for example, knows to call Osborn when she feels tightness in her waist, swelling in her ankles or other symptoms that signify extra fluid.
If a patient isn’t taking care of himself or herself, Osborn gets to the heart of the problem. “There are a number of social situations that can really affect a person’s ability to care for themselves,” she said. “Part of my job as a nurse is to understand what patients’ lives are like and work with them to figure out how they can integrate good heart failure self care into their daily routines.”
Patients appreciate that attention. “We are very happy with my mother’s care at the Brigham,” said Mae Ella Peeples, Hendrix’s mother. “Her doctors (Jennifer Shin, MD, of BIMA, and Paula Johnson, MD, chief of the Division of Women’s Health) and Norma really take the time to answer questions and explain things to us in terms I can understand so I can help my mother understand.”