It’s a familiar situation. An elderly heart failure patient is hospitalized with swollen legs and breathing difficulties, responds well to treatment, and is discharged with a set of written instructions.
Back home – alone – she forgets the dietary guidelines, delays making a follow-up appointment with her doctor, and does not take her medication regularly. Soon her symptoms are back and she returns to the hospital.
One in five older adults in New Jersey is readmitted to the hospital within a month of discharge, according to Healthcare Quality Strategies, Inc. (HQSI), a non-profit, federally-designated quality improvement organization for New Jersey. Healthcare organizations in Atlantic and Cape May counties are now working to avoid unnecessary hospital readmissions through the Atlantic-Cape Community Coalition. The short-term goal is to reduce readmissions by 20 percent within the next three years.
At its kickoff meeting last month, at Atlantic Cape Community College in Mays Landing, more than 22 organizations participated, representing regional medical centers, nursing homes, home health agencies, rehabilitation facilities, the local Office on Aging and the New Jersey Department of Health and Senior Services.
AtlantiCare Healthcare at Home of Egg Harbor Township has begun interventions in which a nurse-coach helps patients understand and follow through with healthcare instructions. Caitlin Lehrfeld, an advanced practice nurse, acts as a liaison among patients, caregivers, and doctors to organize appointments, transportation, medication and more.
Instrumental to the process is use of a Personal Health Record, a booklet that patients can use to collect all of their vital health information in a single place.
“It’s supposed to be with them for doctor’s appointments, hospitalizations – really at all times,” said Lehrfeld. “My number is on the front if they have any questions, and I point them in the right direction.”
Lehrfeld is a constant resource for support, but the goal is to empower patients to take charge of their own health.
“If I do it for them,” she said, “they won’t learn.”
Shore Medical Center of Somers Point is focusing on enhanced care and education for heart failure patients as a way to reduce avoidable readmissions. “We realized it’s not just what happens in the hospital,” said Barbara Juzaitis, administrative director of care management. “We have to go well beyond that point – we need to advocate across the continuum of care.”
“We are thrilled with the enthusiasm and participation we saw at the kickoff in Atlantic and Cape May counties,” said Janet Knoth, RN, of HQSI. “Area residents navigating the health system will see the ultimate benefits. And that, above all else, is our goal.”
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