Nursing Home Readmissions Reduced Using a Novel Heart Failure Protocol


      Congestive Heart Failure (CHF) is among the leading cause for hospital readmissions. Discharge to Skilled Nurse Facility (SNF) occurs in approximately 1 in 5 Medicare beneficiaries after hospitalizations for CHF. Among these patients 23.5% are readmitted to acute hospitals within 30 days. CHF readmissions worsen patient outcomes and are very costly. Increasing onsite physician involvement is often not realistic given existing financial constraints on these institutions.


      Use of a novel heart failure protocol, including remote physician monitoring of data in the electronic medical record (EMR), can significantly reduce hospital cardiac related readmissions from a SNF.


      Upon admission to the SNF, patients were screened for a history of cardiac disease using specific criteria. If criteria were met the heart failure protocol was initiated. A multidisciplinary team including a cardiologist, nurse and a rehab social worker followed the patients during their admission. The staff was educated regarding signs and symptoms of CHF and strict protocols for measuring weights, renal function and brain natriuretic peptide (BNP) were established. Monthly onsite team meetings and weekly webinars were conducted to review patient progress. Automated alerts were setup to notify the cardiologist if a patient’s weight increased or decreased by 3lbs in one week or if BNP rose by 20%. The physician would then direct treatment based on the clinical information.


      In a 3 month period, following an integration phase, 40 patients were enrolled in the heart failure protocol. Of these, 3(8%)were readmitted with a cardiac related diagnosis. In a similar 3 month period prior to protocol initiation 36 patients with a diagnosis of CHF were admitted. Of these, 11(31%) were readmitted with a cardiac related diagnosis. As well, the time the cardiologist spent onsite did not differ between the two intervals.


      Use of a heart failure protocol, including remote EMR monitoring and automated alerts, dramatically reduced hospital readmission from a SNF. This was accomplished without increasing the cardiologist’s presence onsite.