Introduction: With an aging population and growing rates of chronic disease there is a need to provide simple and innovative support strategies for patients after hospital discharge to improve patient outcomes, reduce the burden of disease and reduce the rate of avoidable readmissions. An early post discharge home visit by Community Health Workers [CHWs] is providing support, identifying issues and helping to link acute, community and primary care.
Short description of practice change implemented: XTend is a pilot program utilising CHWs to visit heart failure patients at home within 48 hour of discharge from hospital to identify issues, reinforce the discharge plan, facilitate a medication reconciliation, connect the patient back to their General Practitioner and provide early triage and escalation to the community based Cardiac Chronic Care service.
The CHWs perform a broad shallow assessment of psychosocial issues, perform basic clinical observations, create a patient reported medication list and record a list of questions the patient may have for the GP. Findings are reported back to a supervising nurse and/or the GP for management.
Aim and theory of change: The aim of this initiative is to reduce the 28 day readmission rate and improve the health and wellbeing of patients with chronic heart failure. Changes in medication, poor health literacy and difficulties accessing early GP follow up can challenge patients. Early post discharge follow up aims to provide support to patients and address issues that may result in readmission to hospital
Targeted population and stakeholders
Patients with heart failure tend to be older and have a high rate of readmission within 28 days post discharge. The CHWs work with specialist Cardiac Chronic Care nurses and extend the reach of the nurses by providing early triage and identification of issues.
Highlights: CHWs meet the patient when they are in hospital and visit the patient within 48 hours of discharge. CHWs have identified medication issues or errors in nearly 50% of patients. CHWs see and review the impact of the social determinants of health- refer to services, make links to repair glasses so mediations can be seen etc.
Comments on sustainability: CHWs are more cost effective and have been able to extend the reach of the specialist nurses.
Transferability: The program is looking to extend to a general geriatric patient group at another facility although the model could be applied to any post discharge group of patients.
Conclusions: Between hospital discharge and GP follow up the patient is often vulnerable. Early follow up allows issues that impact on the patients ability to manage their health to be identified and addressed. Issues identified include medication, transport, social support and health literacy.
Lessons learned: The post discharge period is a vulnerable time for patients. The discharge plan and transfer of care to the GP needs to be timely and the issues identified early to reduce readmission risks.
Addressing the issues with medication, health literacy and follow up appointments that are identified by the CHWs has been positive for patients and the health system.