Title:  The CHF Initiative

Organization: Anne Arundel Health System 

Type of Innovation: Care Transitions supported by Admission Readmission Revenue 

What They’re Doing:   Provides support as the patient transitions out of the inpatient hospital setting and Community-based disease management for patients with Congestive Heart Failure  

Clinical Innovation: When a patient with Congestive Heart Failure (CHF) visits the Emergency Department or is admitted to Anne Arundel Health System, the CHF Nurse Navigator applies a “dissection tool” to determine the root cause of the patient’s decline in health status and conducts a structured patient interview to assess the patient’s ongoing needs. The staff works with the patient to develop a care plan, provides patient health education, equips the patient with needed resources to support their care (e.g. free bathroom scales and medication) and ensures a smooth transition post-discharge through follow-up phone calls by nurses, shared electronic medical information with outpatient providers, improved discharge instructions, and follow-up medication reconciliation by nurses when patients transition to skilled nursing facilities.

The staff also connects the patient with clinical and non-clinical support services provided by their partner organizations from across the spectrum of care. Services provided through the partner organizations include home health visits, palliative and hospice care, transportation, patient health education and remote health monitoring. Revisions and improvements of the care strategies are ongoing. 

Supportive Financing Mechanism: Anne Arundel Health System is participating in the state’s Admission Readmission Revenue program.   

Evaluation Type: Quasi-Experimental .

Evaluation Plan: Evaluation that compares admissions, readmissions, and emergency room visits for the local CHF population before and after the implementation of the program. In addition, patient satisfaction, clinician satisfaction and quality of life surveys will be implemented.

Patient Health and Cost Outcomes:   After just the first month of implementation, preliminary data demonstrates a 26% decrease in CHF readmissions.  Statistically significant results will be available in early 2012.    

Target Population: Patients with Congestive Heart Failure in the community served by Anne Arundel Health System

Date of Implementation: July 1, 2011

Contact: Patricia Czapp, MD, 443-481-1150 , pczapp@aahs.org

Multimedia: Pending

Where to learn more: Contact Patricia Czapp at email address above.