At the weight station, a physical therapist or cardiac rehabilitation professional stresses the importance of weighing daily and has the patient demonstrate weighing himself, providing feedback if necessary, to ensure that each patient knows how to properly weigh himself. If the patient does not own a scale, or needs an adaptive scale (such as one with extra large numbers or one that “talks”) and is financially unable to purchase one, he is given one to take home.
At the diet station, a registered dietitian asks the patient what he eats on a typical day, and he is given helpful dietary choices based on his responses. A display at this station provides sample food labels from some common foods, so that patients can see where and how to locate important nutrition information, such as sodium content. The dietitian also discusses fluid restriction and provides the patient and/or caregiver with a written copy of dietary recommendations. In the words of one self-care college patient, “I had to push that salt shaker away, but I also learned that salt comes in cans and boxes. I learned to read food labels for sodium content and to stay away from processed foods.”
At the medication station, a pharmacist reviews the patient’s heart failure medications, has the patient simulate how he will obtain, organize, and remember to take his medications at home, offers feedback and instruction, and answers questions. The pharmacist also provides the patient with a 7-day medication planner for home use and has the patient demonstrate completing the planner.
After the patient has been through the 3 learning stations, a Nurse Link coach enrolls him in the 4-week call-back program. In addition, home health care representatives are available to discuss the benefits of home health to help manage their CHF at home. Finally, each patient receives a CHF self-care college folder, with educational materials including a weight log/calendar; information on smoking cessation, medications, and prescription assistance; a personal health record; control zones for CHF management; red flags and warning signs/symptoms to report; and when to call the doctor.
When the patient has completed the self-care college, the self-care college team “huddles” to ensure that the patient is adequately prepared to transfer to their next health care destination. If not, recommendations are made to their provider to ensure a smooth transition. Family members and/or caregivers are encouraged to participate in the self-care college experience whenever possible and are included in the huddle.
Implementation
Prior to implementing the self-care college, the team identified 4 major challenges and developed strategies to address them. In many cases, strategies were effective in addressing more than one challenge.
- Coordinating the allocation of resources among different departments: as with any new initiative, finding time in everyone’s schedule to accommodate additional tasks is a challenge. In order to ensure that the self-care college was streamlined into everyone’s schedule, the team determined a set time of day that it would take place.
- Gaining buy-in from referring physicians: because referrals from physicians would be critical to the success of the self-care college, the team spent significant time meeting face-to-face with physicians to explain the reason for the program and how it would be implemented. In almost every case, physicians enthusiastically agreed to refer appropriate patients to the self-care college. Although NMHS operates in a fee-for-service environment (and physicians therefore are not financially incentivized to reduce readmissions), it has a strong culture of compassion and caring, focused on innovation, vision, and performance results. Physician buy-in was also facilitated by rolling out the program one floor at a time, so that the team and the physicians could become comfortable with the process. The nurses and case managers on each unit were educated about the program and could prompt the physician to consider placing a referral to the program if warranted.
- Logistical issues in getting the patients to the self-care college room: many CHF patients have significant mobility challenges, and the team discovered that it was not always possible for the patient to be transported to the room where the self-care college was set up, particularly as the program expanded into different wings of the medical center. As a result of feedback from patients and staff regarding the logistical issues around transporting patients to the college, the team developed a mobile version that is brought directly to the patient’s room. A cart holds scales, patient folders, medication planners, and all the tools necessary to present the program. Each member of the team rotates into the room to present their piece of the program. In addition to ensuring that patient mobility issues were not an obstacle to participation, developing the mobile program made the most efficient use of the team’s time in serving these patients, and no patient has been turned away due to having reached capacity at the stationary self-care college.
- Completing the self-care college in a timely fashion: In order to make most efficient use of time (for both the team and the patient), the content for each station was designed to last no more than 15 minutes on average. We have also worked with physicians to encourage referrals prior to the day of discharge, so that patients can be scheduled efficiently.