Recently the Centers for Medicare & Medicaid Services announced a bundled payment model associated with the impending roll out of the Medicare Access and CHIP Reauthorization Act legislation. This means a hospital will receive a single, target-price reimbursement for an entire 90-day episode of care associated with an acute myocardial infarction (AMI) admission. At Advocate Good Samaritan Hospital in Downers Grove, Ill., we have taken a proactive approach to deal with this change by focusing on how nursing can impact the care of our AMI patients.
We sought input from bedside nurses, nursing leadership, advanced practice nurses and cardiologists in addition to researching literature and evidence-based techniques. The result: a single, comprehensive program for the management of patients presenting for primary management of AMI both during the inpatient phase of care and the immediate post-hospital transition phase.
Both the bedside nurse and the patient receive a road map at the initiation of inpatient phase I cardiac rehabilitation. The road map details education, treatment, and activity expectations from admission to discharge. For uncomplicated patients, we selected a 48-hour goal to discharge. The remaining components of our AMI clinical pathway include:
- Planned early ambulation.
- Nutrition consultation.
- Teach-back. Numerous experts recommend using the teach-back method at the end of every patient education session regardless of the patient’s health literacy level. The technique has been shown to have a positive impact on disease-specific knowledge and treatment plan adherence and has been associated with a trend toward improved self-care and reduced hospital readmissions. The goal is to convey adequate information to facilitate immediate post-discharge self-care and prevent short-term readmission (prior to initiation of outpatient cardiac rehabilitation) without overwhelming the patient. The teach-back questions will be shared with our home health and cardiology physician partners to ensure consistent patient education throughout the continuum of care.
- Standardized patient-facing materials. Patients report feeling confused and overwhelmed by the volume of educational materials they receive. On the program go-live date, existing materials will be replaced with a custom education offering based on the teach-back questions used for inpatient education.
- Pharmacist-led discharge medication reconciliation. A recent meta-analysis found that pharmacist-led medication reconciliation programs at care transitions are associated with a substantial reduction in all-cause hospital readmissions.
- Automatic referral to outpatient cardiac rehabilitation.
- Heart attack patient promise. Patient contracts establish clear expectations for post-discharge patient self-management and document the patient’s commitment to participation in their own care. Our patient promise is composed of open-ended questions designed to supplement inpatient education, provide a framework for patient engagement, and summarize the patient’s immediate post-discharge responsibilities. The contract is to be completed on the date of discharge with the patient by either a cardiology advanced practice clinician or a nurse.
- See you in seven. All patients with home health services will have a cardiology follow-up scheduled within seven days of discharge prior to departing the hospital. Patients without home health services will follow up with cardiology in 48-72 hours.
- Post-discharge electronic follow up. Patients will receive an e-mail communication on the first business day after discharge including their cardiologist’s electronic business card, their primary care provider’s electronic business card and links to reputable internet resources.
- Transition management by advanced practice clinicians. Cardiac advanced practice nurses have been shown to have a positive impact on 30-day emergency department and hospital readmissions. Home health nurses will have an open line of communication with the appropriate cardiology advanced practice team to resolve post-discharge problems before they result in readmission.
Our AMI Clinical Pathway is built on a foundation of shared expectations. When they know what to expect during their hospitalization, we’ve discovered that patients and their family members are more engaged and feel less anxious about what lies ahead.