Case Study: UPMC Pinnacle 2019 HAP Achievement Award
Awarded for: Heart Failure Hospitalist Team: An Example of Interdisciplinary Excellence
Excellence in Care
Large Organizations
The goal: To improve continuity of care for heart failure patients and reduce avoidable readmissions.
An interdisciplinary heart failure team created a heart failure hospitalist service to support an environment of patient-centered care across the continuum.
The heart failure hospitalist team:
- Provides evaluation and management and optimizes patients’ medications
- Educates patients and families so they can understand and follow treatment plans
- Introduces the concepts of palliative and hospice care
- Coordinates care with outpatient providers
- Supports patients’ self-management of outpatient care through visits to review action plans, goals of care, medication reconciliation, and education
The team also implemented innovative techniques such as:
- The use of paramedics to carry out intravenous diuretic protocols in patients’ homes
- Virtual doctors’ visits via telemedicine
- Technology to monitor patients’ conditions in order to prevent readmissions
Results: The program resulted in:
- Decreased length of stay for heart failure patients
- A nearly 50-percent reduction (to 9%) in the 30-day all-cause readmission rate compared to the readmission rate for heart failure patients not supported by the heart failure hospital team and national readmission rate averages
- Reduced costs
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Topics: Public Health, Quality Initiatives
Revision Date: 9/1/2019
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