This multidisciplinary initiative was launched in March 2020 in response to a sharp decrease in the number of hospitalized heart failure patients during the spring of the COVID Pandemic.
The concern was that heart failure patients were not seeking care during this time or delaying their care and becoming sicker at home. Case management, population health, social work, community health and their leadership worked together to implement this program.
The team met weekly to discuss the most complex patients and strategize interventions to best support these patients during this time.
For consistency, Josh Margaritondo, Elizabeth Cummings, and Lynn Kasmer developed a script specific for this targeted outreach. A shared EPIC smart phrase (.HFFU) was used to document and track the volume of this outreach.
During these calls, the nurses and social workers conducted brief clinical triage, which ensured that patients:
- had all of their medications and were taking them properly
- were scheduled for their follow-up appointments
- were receiving home health services when necessary
The callers also assessed patients’ telehealth readiness. Any issues identified during this outreach were addressed or escalated to the appropriate providers to address.
This outreach concluded at the beginning of June due to an increase in the inpatient heart failure census. Through this emergency high-risk outreach, this team:
- educated patients on telehealth options
- encouraged patients to complete their follow-up appointments and assisted in scheduling their appointments when necessary
- requested refills for patients who had run out of their medications
- advised patients to return to the hospital, when necessary, for evaluation
- initiated home health for patients who needed it and educated patients on home health being available to them during COVID-19
- communicated with providers promptly, which often resulted in patients having same-day or next-day appointments to address their symptoms keeping them out of the emergency department
- improved efficiency of escalation logistics to the heart failure team as well as improved communication with preferred home health providers
Patients with whom we spoke were very grateful for our calls to check on them. When we gathered ‘voice of the customer’ data on the call cadence of various outreach calls, the response from patients and their families was positive.
Comments included “They’re great. I’ve never had this kind of service” and “To be honest, all the calls have been necessary to help my grandma recover. It’s not like you’re just calling to waste our time. Every call has a purpose and we’re very grateful for everything.”