To assist in care coordination and improve outcomes for heart failure patients, Our Lady of Lourdes Memorial Hospital developed the innovative Coordinated Outreach Achieving Community Health (COACH) for Heart Failure program.
This nurse-driven inter-professional approach to patient care includes: one-on-one patient education provided by cardiovascular disease managers (nurses), dieticians, and physical therapists; consults from palliative medicine, cardiology, and cardiac rehabilitation, when appropriate; and assistance with follow-up arrangements. Primary care and cardiology appointments are also scheduled for patients prior to discharge. Home care and telehealth services are arranged, scales and blood pressure cuffs provided, and transportation coordinated for those who need assistance. Patients also receive follow-up calls and may receive home visits from the cardiovascular disease manager if they choose not to participate, or are not eligible for home care.
This program resulted in a number of positive outcomes, including reducing heart failure readmissions by 30%; addressing barrier issues for patients related to medication auto-refill, transportation, and access to providers; and improving communication across the continuum of care.