The CABG patients who did not receive home health care through the Follow Your Heart program were three times more likely to either be readmitted to the hospital or pass away, the study found. The 30-day readmission rate for patients receiving the typical care after this surgery was 11.54 percent, while those receiving home health care had a readmission rate of 3.85 percent.
A total of 401 patients participated in the study with 169 receiving cardiac surgery nurse practitioner (NP) home visits and 232 receiving usual care following CABG. In Follow Your Heart, a cardiac surgery NP, who helped care for the patient in the hospital, visited the patient at home twice within the first 14 days after discharge. The NPs provided directed physical exams, medication management and served as the communications hub for the patients and all pertinent care providers, including community resources such as family practitioners and cardiologists. The NPs are equipped with encrypted smart phones to provide email reports to care providers and send pictures back to the surgeon for advice about wound care if needed.
Having this continuity of care from a cardiac surgery NP greatly impacted the patients at home. The NPs provided more directed management for the patients and ensured that patients were following appropriate, updated instructions, according to Michael Hall, MD, division chief of adult cardiac surgery at NSUH. In addition, communication with community providers helped prepare them for the handoff of the specific patient after the first two weeks. This greatly prevented adverse consequences including readmission with added cost savings.
"We found that patients sometimes were not obtaining new medications because of cost issues, taking old medications with the mistaken belief that they were just as good, and failing to see community physicians because of lack of transportation, among many other things," Dr. Hall said. "All patients have specific needs that need to be individualized after discharge. We found that most problems could be solved by our nurse practitioners, who already knew the patients, once they were in the home."