Purpose

The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model.

Methods

An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge.

Results

Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted.

Implications

The IPC was effective in decreasing HF readmissions.

Conclusions

These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF.