NUR 650 Module 3 Milestone One Example

Milestone One: Analyzing 30-Day Heart Failure Readmissions Through Data, a Process Map and Root Causes

[Student Name]

Southern New Hampshire University

NUR 650: Care Coordination and Outcomes Management

Module Three Milestone One

[Instructor Name]

[Date]

Milestone One: Analyzing 30-Day Heart Failure Readmissions Through Data, a Process Map and Root Causes

When readmission rates are high, the pressure to act quickly can lead a hospital to choose an intervention before understanding the problem. At Brookhaven, a composite 280-bed regional hospital, heart failure patients have returned within a month at a steady 24% for three years, above the national average, and administrators have proposed adding a nurse phone call two days after discharge. The phone call may help, but no one knows whether it addresses the reasons patients return. Nationally, Jencks et al. (2009) found that heart failure was among the most common conditions leading to rehospitalization in Medicare. This milestone analyzes Brookhaven's problem before recommending any intervention. It argues that defining the population, examining data on timing and cause, mapping the process and identifying root causes will point to interventions more likely to work than the one first proposed.

Defining the Population

The population comprises adults discharged alive from Brookhaven with a principal diagnosis of heart failure, excluding patients discharged to hospice, transferred to another acute hospital or leaving against medical advice, since these patients follow different pathways. Using this definition, Brookhaven discharged 400 patients in the most recent year. Their median age was 76; 58% were Medicare beneficiaries without supplemental coverage and 14% were dually eligible for Medicaid; 31% lived alone; and 38% lived in the two rural counties the hospital serves, where the nearest cardiology clinic is more than 40 minutes away. Readmission is defined as an unplanned admission to Brookhaven or either of two nearby hospitals that share data within 30 days of discharge, for any cause.

What the Data Show

Of the 400 patients, 96 were readmitted within 30 days. Timing was concentrated early: 39 (41%) returned within the first seven days and 67 (70%) within the first fifteen. Of the 96, only 30 had seen any clinician between discharge and readmission. A chart review of all 96 readmissions, conducted by the clinical nurse leader and a heart failure nurse practitioner using a structured form, classified the primary reason for return. Volume overload accounted for 50 readmissions, other cardiac causes for 14 and noncardiac causes, such as pneumonia or falls, for 32. Among the 50 volume overload readmissions, the charts documented that 22 patients had stopped or reduced their diuretic, 15 had not weighed themselves or had not known what to do with a weight gain and 11 could not afford or obtain their medications.

The early timing matters. Hernandez et al. (2010) examined Medicare patients hospitalized for heart failure and found that where more patients were seen within a week of discharge, hospitals had lower 30-day readmission rates than those from hospitals where early follow-up was less common. The current joint cardiology guideline considers an early follow-up visit, generally within seven days of discharge, reasonable for patients hospitalized with heart failure and recommends multidisciplinary disease management for patients at high risk of readmission (Heidenreich et al., 2022). At Brookhaven, only 31% of all heart failure patients had a documented visit within seven days.

Mapping the Process

The clinical nurse leader mapped the process from admission to day 30 by walking the pathway with a patient's chart, interviewing nurses, pharmacists, case managers and clinic schedulers and observing three discharges. The map revealed six handoffs and four points where the process frequently failed. First, discharge teaching occurred on the day of discharge, often in the last hour, when patients were tired and focused on leaving. Second, the follow-up appointment was written as "within 7 days" but left to the patient to schedule in 70% of cases, and rural patients often could not get an appointment that soon. Third, the discharge summary was sent by fax to the primary care office, where staff reported that it often arrived after the visit. Fourth, no one was assigned to contact the patient between discharge and the first visit, so early weight gain went unnoticed until symptoms brought the patient to the emergency department.

Root Causes

A fishbone diagram was built with staff from each discipline, grouping causes under patient, process, communication and resources. The chart review data were then used to count how often each cause contributed, producing the Pareto analysis in Table 1. The largest single cause was the absence of clinician contact in the first week. The next three, diuretic misunderstanding, weight monitoring failures and medication access, are all patient self-management problems that early contact could detect. Together, these four causes account for about 73% of the causes identified. Noncardiac readmissions are significant but less amenable to a heart failure program.

Table 1. Pareto Analysis of Contributing Causes Among 96 Readmissions

Note. Many readmissions had more than one contributing cause, so counts sum to more than 96; cumulative percentages are calculated on 144 total cause assignments.

What This Means for the Proposed Phone Call

The analysis suggests that a single phone call at 48 hours would address part of the problem, early contact, but not the rest. It would not ensure a visit within seven days, would not fix last-minute teaching and would not solve medication cost or rural access. The interventions most likely to work would combine teaching spread across the stay with teach-back, a follow-up appointment booked before discharge, early contact with a way to act on weight gain, medication access checked before discharge and a direct handoff to primary care. These findings will guide the comparison of transitional care models in Module Four.

Aim Statement

By the end of the next fiscal year, Brookhaven will lower all-cause returns within 30 days among adults discharged with heart failure from 24% to 19%, and will increase the proportion of these patients with a clinician visit within seven days of discharge from 31% to 70%. Both measures will be tracked monthly and reported to the quality committee.

Conclusion

The proposed phone call would have been a reasonable guess. The analysis shows why it would not be enough: most readmissions happen early, most patients have no contact before they return, and the underlying causes are gaps in understanding, monitoring and access that a single call cannot fix. Defining the population, examining data, mapping the process and ranking root causes have given Brookhaven a clearer target and an aim it can measure.

References

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895-e1032. https://doi.org/10.1161/CIR.0000000000001063

Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., & Curtis, L. H. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA, 303(17), 1716-1722. https://doi.org/10.1001/jama.2010.533

Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418-1428. https://doi.org/10.1056/NEJMsa0803563