Skip to main content
UC Davis Medical Center

UC Davis Medical Center

FEATURE | Posted Oct. 17, 2013

Reducing hospital readmissions for heart failure

Nurse-pharmacist teams key to better outcomes

Patient Gerald Ferguson © UC Regents
Gerald Ferguson, recently digagnosed with congestive heart failure, has reduced his sodium intake, stopped smoking and tries to get outdoors more to enjoy one of his favorite hobbies, photography.

Sacramento resident Gerald Ferguson, 64, isn’t sure how long he’s been suffering from congestive heart failure (CHF), but he does know when the condition got his attention.

“I woke up in the middle of the night and my heart was pounding, and I was breathing like I was running out of air,” Ferguson said.

A trip to UC Davis Medical Center’s emergency department soon confirmed that he had a serious, potentially fatal, condition. He was quickly admitted and his condition stabilized. And although he was discharged a few days later, that wasn’t the end of his problem. Ferguson now had to manage his chronic disease.

Controlling CHF

Congestive heart failure is a very common condition, which the National Heart Lung and Blood Institute estimates affects about 5.8 million individuals in the U.S. alone. It is a leading cause of hospital stays among people on Medicare.

The condition can stem from previous heart attacks, long-term high blood pressure, a congenital valve defect or even genetic problems with heart muscle proteins. As a result, the heart can’t pump enough blood to meet the body’s demands. Patients feel weak, congested and fatigued. Poor blood flow causes fluid buildup around the heart, lungs and other parts of the body.

CHF is fatal, but before it kills, it often destroys quality of life. Patients can be too weak to perform the simplest activities: getting dressed, going to the store and walking to the mailbox. However, with proper management, people can regain these capabilities and spend less time in the hospital.

Comprehensive approach to care

Kathleen Tong © UC Regents“ Heart failure is a complex condition, and you need everybody involved: pharmacy, nursing, social work, physicians and clerical staff.”
— Kathleen Tong

Patients with heart failure have complex medication regimens and dietary restrictions requiring frequent medication adjustments and monitoring. They also often have difficulty in adhering to complex treatment, which may lead to a more rapid progression of their disease and problems that require emergency care or hospitalization.

In 2011, UC Davis assistant professor of cardiology Kathleen Tong established a comprehensive, multidisciplinary approach to heart-failure care that has reduced UC Davis Medical Center readmissions to as low as 13 percent in 2013 – well below the national average of 24 percent.

Nurse-pharmacist teams

UC Davis Health System’s comprehensive approach to caring for heart failure patients involves strong collaboration among three different teams:

  • Transition-of-Care team for hospitalized patients
  • Outpatient Heart Failure Clinic for patients with complex medical needs and their families
  • Chronic Disease Management Care and Education program for patients treated in UC Davis’ primary care clinics.

The collaboration includes a nurse practitioner, clinical nurse specialist, two registered nurses and three pharmacists who help patients and their physicians overcome challenges to successfully managing heart failure.

The program excels at identifying heart failure patients and following up. This means providing timely case management, education and ongoing assistance.

“By educating patients, we empower them to take better care of themselves,” Tong said. “We help them with medication adherence and understanding what the drugs do. We counsel them on lifestyle choices and help them understand the symptoms that indicate their heart failure is getting worse. All of this helps to keep them healthier and out of the hospital.”

But it’s only half the battle.

Tong has found that it’s equally important to have dedicated nurse and pharmacist teams available across the continuum of care – in the hospital, cardiac specialty clinic and primary care offices – to meet the diverse needs of low- and high-risk patients and help them successfully manage their conditions.

The teams help resolve a wide range of patient and operations-related difficulties. They help patients make follow-up appointments, facilitate communication between health-care providers, alleviate confusion over prescribed medications and address transportation issues.

“Heart failure is a complex condition, and you need everybody involved: pharmacy, nursing, social work, physicians and clerical staff,” she said.

Straight Talk

Ferguson only spent a few days in the hospital, but he had to make a deal with Tong to get discharged.

“She told me I could get out on Friday, but only if I came to the clinic on Monday,” Ferguson said. “I said, ‘Doc, under the circumstances, I don’t think you have a lot to worry about.’”

Though no one wants to be diagnosed with a chronic heart condition, Ferguson appreciates the straight talk.

Nurse works with heart failure patient © UC Regents
Alisa Dieterich, a nurse practitioner and member of the Outpatient Heart Failure Clinic team, reviews prescribed medications with patient Ray Vancor.

“I didn’t want the information sugar-coated,” he said. “I wanted the cold, hard facts. It’s the only way I could deal with conducting my life.”

For Ferguson and other CHF patients, the cold hard facts mean multiple medications, including diuretics to keep fluid levels down. Patients must also restrict alcohol, and liquids of all types, as well as reduce salt intake and stress. The heart failure clinic staff follow up periodically to ensure he’s on track.

“We want to teach patients how to improve their lifestyle in practical ways,” Tong said. “Not everyone can afford to shop at Whole Foods.  But we point out to patients, for example, if they eat frozen green beans instead of canned, they can really reduce their salt burden.”

Equally important, the clinic helps patients like Gerald Ferguson learn about their condition and make tangible changes to improve their health and well-being.

“I’ve known a number of people with congestive heart failure,” Ferguson said. “Those who listened to physicians and took care of themselves are doing alright, and those who didn’t are feeding tulips. That’s not something I want to be doing.”