Use of Standardized Discharge Education Program (SDEP) and gollow-up phone calls to reduce heart failure readmissions

Improved coordination and collaboration to ensure continuous care for the chronically ill is needed within rural communities for the improved health benefit of rural patients. A gap exists between current discharge teaching and post-discharge follow-up for patients diagnosed with heart failure. The purpose of the project was to decrease heart failure hospital readmissions in adults 65 years of age and older and increase the patient follow-up visit rate with primary care providers after hospital discharge. Patients were educated on the purpose of the project and texted four scheduled weekly texts containing a video link for heart failure specific self-care management educational sessions, lasting 5-6 minutes, and were encouraged to schedule a follow-up visit with their primary care provider within a week of receiving the final educational text. The impact of the standardized discharge education (SDEP) resulted in a reduction in hospital readmission rates of 100% (n = 7) from the last quarter of 2022 to the first quarter of 2023 at the privately owned nurse practitioner clinic. At the end of the 12-week initiative, all participating patients (n = 7, 100%) made follow-up appointments with the primary care provider. The results of this project indicate a nurse-led SDEP can increase patient understanding of heart failure and self-care management, thus reducing 30-day hospital readmission rates. Follow-up phone calls remind patients to follow-up with their primary care provider and offered an opportunity for patients to ask clarifying questions. Earlier post discharge visits with the primary care provider can result in earlier intervention, lowering the risk of emergency room visits and hospital readmissions.