plan proposal for an interprofessional team to collaborate and work toward driving improvements in the organizational issue identified in the second assessment.
SOLUTION
1. Introduction
Congestive heart failure (CHF) continues to be a leading cause of preventable 30-day hospital readmissions, impacting patient health outcomes and imposing financial penalties on health care organizations. Based on the interview conducted with a nurse manager, and review of national quality data, it was identified that Oakridge Health System would benefit from an interprofessional initiative focused on reducing CHF readmissions. This proposal outlines the structure, roles, goals, and communication plan for a collaborative team tasked with addressing this issue.
2. Goal of the Initiative
The primary goal is to reduce 30-day CHF readmissions by 25% within one fiscal year through coordinated interdisciplinary efforts in discharge planning, patient education, and follow-up care.
Objectives:
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Improve discharge education and medication reconciliation.
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Enhance patient engagement and self-care management.
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Ensure timely outpatient follow-up within 7 days of discharge.
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Address social determinants of health through case management and social work support.
3. Proposed Interprofessional Team Members and Roles
| Team Member | Role in Initiative |
|---|---|
| Primary Care Physician (PCP)/Hospitalist | Lead medical management, coordinate discharge orders, ensure communication with outpatient providers. |
| Registered Nurse (RN) | Provide patient education on CHF management, monitor symptom recognition, facilitate communication during transitions of care. |
| Pharmacist | Conduct medication reconciliation, counsel on CHF medications, ensure discharge prescriptions are filled and understood. |
| Dietitian/Nutritionist | Counsel patients on low-sodium diets and fluid restrictions, provide printed materials and follow-up sessions. |
| Case Manager | Coordinate discharge planning, confirm home health referrals, and schedule outpatient follow-ups. |
| Social Worker | Assess and address housing, transportation, caregiver support, and financial barriers that may affect post-discharge care. |
| Home Health Nurse | Conduct home visits, monitor vitals, reinforce education, and alert providers of worsening conditions. |
4. Plan of Action
A. Discharge Bundle Implementation
Develop a standardized CHF discharge bundle to be used by the care team before discharge. Components include:
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Medication reconciliation and explanation
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Printed CHF action plan (symptoms, diet, activity, when to call)
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Scheduling of 7-day follow-up with PCP or cardiologist
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Home health referral (as needed)
B. Weekly Interdisciplinary Rounds (IDR)
Implement structured IDR for CHF patients, involving team members to review discharge readiness, address barriers, and align care plans.
C. Use of a CHF Care Pathway in the EMR
Embed a clinical decision support tool in the EHR that prompts documentation of education, follow-up scheduling, and referrals for all CHF patients.
D. Staff Training and Accountability
Hold in-service training sessions on CHF management protocols and the importance of interdisciplinary collaboration. Assign team leads to track performance metrics.
5. Communication and Collaboration Strategies
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Weekly Team Huddles: Brief, 15-minute updates led by the case manager to assess progress, identify challenges, and clarify roles.
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Shared Documentation: All team members document interventions and findings in a shared EHR note labeled “CHF Care Plan.”
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Care Coordinator Role: Appoint a care coordinator to bridge inpatient and outpatient communication and to follow up with patients post-discharge.
6. Metrics for Evaluation
| Outcome | Target | Measurement Tool |
|---|---|---|
| 30-Day Readmission Rate | ↓ 25% | CMS Readmission Reports |
| Patient Understanding of CHF Plan | 90% “satisfactory” | Patient post-discharge phone survey |
| Follow-Up Appointment Completion | ≥ 85% within 7 days | EHR Scheduling Reports |
| Home Health Engagement | 100% of referred patients receive a visit within 48 hours | Home Health Logs |
7. Evidence-Based Support
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Naylor et al. (2018) emphasize that transitional care models with nurse oversight can reduce CHF readmissions significantly.
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The American Heart Association and the American College of Cardiology (2022) recommend multidisciplinary CHF care teams to improve long-term outcomes.
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CMS and the Institute for Healthcare Improvement (IHI) support using team-based interventions and discharge bundles as quality improvement measures.
8. Conclusion
The complexity of CHF management requires a coordinated, interprofessional approach. By leveraging the expertise of a diverse health care team, Oakridge Health System can reduce unnecessary readmissions, improve patient satisfaction, and optimize care transitions. This plan provides the framework for operationalizing collaborative care and tracking measurable progress in addressing this significant clinical issue.
References
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Naylor, M. D., et al. (2018). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 66(3), 401–410.
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Yancy, C. W., et al. (2022). 2022 ACC/AHA/HFSA guideline for the management of heart failure. Journal of the American College of Cardiology, 79(17), e263–e421.
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Institute for Healthcare Improvement (IHI). (2021). Improving transitions of care to reduce readmissions.
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Centers for Medicare & Medicaid Services (CMS). (2023). Hospital Readmission Reduction Program (HRRP). Interprofessional Team Plan Proposal: Reducing CHF Readmissions appeared first on Skilled Papers.
