1. Home Health Education, Special Meal Provision, and the Heart Failure Patient Christine A. Rovinski, ARNP, MSN OEF OIF Program Manager Veteran Affairs Medical Center White River Junction, VT

2. OBJECTIVES At the completion of this presentation, the participant will be able to: Identify two strategies that enhance effective patient communication; Recall two strategies to support patient engagement in chronic disease self-care management.

3. BACKGROUND Higher than desired utilization rates (hospital admission, inpatient length of stay and Emergency Room) for some diagnostic categories Heart Failure targeted (VHA national focus)

4. BACKGROUND Medical record review revealed: repetitive patient education and staff not changing methods of instruction.

5. What Happened Next? Discussions and brainstorming among inpatient and home care clinicians and clinical and nonclinical departments. Idea was submitted to Veterans Affairs New England Network for consideration as a 2009- 2010 Innovation Project. Project to observe the effect of concurrent home health education and low sodium meal delivery on the dietary habits of heart failure patients was approved and funded.

6. Pilot Population Anticipated: 20 patients Actual: 4 patients Limitations: geography/logistics patient choice

7. Existing Staff Tool-box Effective Patient Education Face-to-face education Real-time education Interdisciplinary team Patient education materials Support Patient Engagement Longitudinal home care program (routine and continuous care provision throughout the course of a chronic disease) Home tele-health

8. WHAT ELSE was NEEDED?

9. Enhanced Staff Skills & Improved Tool Box

10. Reviewed evidence-based resources Constructed Trans-disciplinary Heart Failure Care Path Incorporated patient self-determination materials into the teaching process Educated staff about motivational interviewing Best practice of volunteer training and meal delivery determined through community site visits and adapted for hospital-to-home provision.

11. Trans-Disciplinary Care Planning (enhance effective patient education) Requires sharing knowledge, skills, and responsibilities across traditional disciplinary boundaries in assessment and service planning Involves boundary blurring between disciplines Strengthened by cross-training and flexibility in accomplishing tasks

12. Motivational Interviewing (support patient engagement) Patient centered approach Discovering what is important to the patient Directive Exploration of patient ambivalence Use of systematic strategies to engage patient’s involvement

13. Shared Decision Making (support patient engagement) Means of coming to an agreement about healthcare Collaboration between provider and patient Encourages patient participation in decisions about healthcare

14. Findings 100% achieved blood pressure management within nationally defined parameters during meal provision, and maintained blood pressure within the same parameters for 12 weeks after delivery ceased. 75% had diuretics discontinued or dosages decreased 86% reduction in hospitalization and/or ER utilization related to heart failure achieved

15. Conclusion A combination of highly individualized education and concurrent disease-specific meal delivery is effective in changing the dietary habits of heart failure patients.

16. Recommendations for Future Study Replicate project with larger heart failure population. Formulate dialogue and response scenarios to counter patient objections and facilitate participation. Formulate contingency plans to address changes in team membership and difficulties in finding patients who meet project inclusion criteria. Adapt project findings to diagnostic categories in which patients typically have a difficult time adapting to dietary changes to effect improved health, e.g., diabetes.

17. It’s not what you know….. It’s what you do with what you know.

18. Questions?