Congestive Heart Failure (CHF) can be a debilitating condition, which decreases quality of life and consumes significant healthcare resources. John T. Mather Memorial Hospital in Port Jefferson started its CHF program to improve the continuity of care, reduce readmissions, and improve quality of life for heart failure patients.
A nurse practitioner provides transitional care and follows the patient for 30 days post-discharge, stressing the importance of keeping doctor appointments, following their prescribed low-sodium diet, monitoring their weight daily, and taking their medications as directed. A support group provides patients with continued education and support after the four-week period ends.
As a result of the program, the rate of 30-day readmissions to Mather Hospital for CHF patients was reduced by more than one-third and the rate of potentially preventable readmissions was reduced by more than half. Patients also had a 92% average increase in their quality of life scores at the four-week follow up appointment.