1. Evidence Based Medicine Congestive Heart Failure Initiative Allen Hospital, New York Presbyterian NYAM review session August 10 th 2011

2. Evidence Based Medicine Approach – Project began September 2009 – Learned the Basic Skills and Principles of EBM How to ask a question How to perform a relevant search Evaluation and Interpreting articles Principles of guideline evaluation and development

3. #1 Choose a project that counts! – Who are your customers? Doctors: Clinical benefit Hospital: Financial benefit Patients: Improved care

4. #2 Involve everyone that matters! Multidisiplinary Team ER: Dr. Leslie Miller, Dr. Peter Wyer Hospitalist: Dr. Beth Barron, Dr. Zorica Stojanovic, Dr. Eugene Wong Cardiology: Dr. Gerald Neuberg, Karen Stugensky, PA Quality: Avi Fishman, Mary Ellen Hickman Librarian: John Oliver IT: Amalga: Niloo Shobhani Social Work: Eileen Kornfield Nutrition: Susan Fulton Care coordination: Donna Tingling-Solanges, Doug Morton Nursing: Kelly Maydon, Alan Levine, Mitzy Placencia Patient Education: Jody Scopa Goldman Administration: Michael Fosina VP – Executive Director of Allen Hospital

5. # 3 Know what your problems is Internal scan – Who are our patients? (chart review, patient calls, staff survey) Admitted from? Discharged to? Services? Insurance? Private physician? When and if follow up scheduled? What medications d/c home on? Smoking? Diabetes? Other co-morbidities? What do the patients think about our care? External scan – What is in the literature? Home care, Health literacy, Medications, Language barriers, Patient education, Economic, Prediction rules, and Cardiology evaluation

6. #4 What will work for Allen? Knowledge Translation Group reviewed the evidence, reviewed external guidelines and our internal reviews Agreed that we would focus on education and the transition of care from hospital to outpatient primary care doctor Spanish language capabilities a must

7. Project began 11/15 Mitzy Placencia, CHF RN – Inpatient education (Patient education handbook) – Core measures evaluation – Outpatient phone calls until seen by primary – Trouble shooting (medications, f/u visits) – Scales – Nutrition consults

8. CHF Education and Follow Up Pathway Day 1 Patient is admitted through the ED Patient admission notes are screened for appropriateness of education. Patient educated on: What is CHF Daily weights Sodium and Fluid Restrictions When to call the physician

9. CHF Pathway Cont. Day 2 Review sodium and fluid restrictions Review medications with the patient and family Day 3 Review discharge teaching: What to do if you notice an increase in symptoms When to call the physician and when to come to ED.

10. After Discharge… The patient is called at home 2-3 times a week for one month Medications reconciled Symptoms assessed Family members and Home Attendants educated also Troubleshooting: Earlier appointments, medications refilled, diuretics doses increased if necessary and more… Education continues!

11. Collaborations With Other Healthcare Professionals CHF classes held on a weekly basis with nutrition. Weekly meetings with VNSNY Phone calls to the field nurse of various homecare agencies to discuss the patients’ progress and status.

12. #5 Measure your successes and be willing to change/evolve Volume Impact of early follow up Issues identified with readmitted patients Impact of keeping in touch

13. CHF RN Coordinator monthly patients volume (11/15/10 -7/31/11 )

14. Impact of early follow up All 198 patients had follow up appointment scheduled before discharge: < 7 days: 111 patients (56%) > 7 days: 87 patient (44%)

15. Impact of early follow up on readmissions 8 patients (9.2%)% with f/u<7 readmitted 23 patients (20.7%) with f/u>7d readmitted

16. Impact of keeping in touch Post discharge phone call attempted on all patients seen in hospital. Only 7 of them were unreachable 5 out of 7 were readmitted

17. CHF 30 Day Readmission Measures Allen Hospital Q1 20102010Q1 20112011 (Jan- May) Readmis sions 27.5%28.36%18.31%20.16%

19. Zorica’s lessons learned slides We offered one size fits all (education and transition of care) approach… and added Many different interventions were needed for each individual patients.

20. Positive impact NYP impact Allen impact – Future projects?