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Nurse-led clinics battle readmissions


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Alexandra Wilson Pecci, for HealthLeaders Media, August 28, 2012

A nurse practitioner is at the helm of a free healthcare clinic that aims to reduce readmissions among congestive heart failure patients. It's one of the latest of many free, nurse-led clinics and programs that are bridging gaps in healthcare for patients across the country and, in the process, reducing hospitalizations and readmissions, saving money, and keeping patients healthy.

The Mountain States Health Alliance founded the congestive heart failure clinic at the Johnson City Medical Center in Tennessee. According to MSHA, (which was also just awarded the 2012 National Quality Healthcare Award by the National Quality Forum) about one out of every three congestive heart failure patients is readmitted to Johnson City Medical Center within 30 days.

The clinic, located on the medical center campus, will focus on education, medication reconciliation, and helping patients monitor their conditions. In addition, clinic staff will help patients utilize medication and other assistance programs and resources.

Although the staff won't dispense medicines, Julia Bates, the nurse practitioner who helped create the care model for the clinic, said that her job will be to make sure patients understand congestive heart failure. She'll also work to identify and help patients overcome the social and financial barriers that might prevent them from getting better.

"Many family practices don't have enough time to focus on this, so we will provide as much education as the patient needs," she said in a statement.

Nurses play a pivotal role in providing these very basic, but too often unmet needs in the community. It's almost strange to think about such simple interventions such as making sure patients

  • Understand their health conditions,
  • Know how to take their medications properly,
  • Have access to programs that can help them financially


is one that's so influential, but is also so easy to overlook. Nurses, without even dispensing medicines, can act as powerful agents of change for patients who might have otherwise slipped through the cracks.

The benefit isn't only for patients, however.

Hospitals and medical centers that make the investment in providing this kind of care also reap benefits down the road. I'm reminded of a hospital-to-home program at Mercy Health-Fairfield Hospital in Fairfield, Ohio, which assigns care transition coaches at discharge to patients who are at high risk for readmission.

A pilot version of the program decreased the readmission rate for the target population to 7.5%, which is about a third of the national rate. Mountain States Health Alliance leadership says the congestive heart failure clinic's goal for the first year is to reduce its total congestive heart failure readmissions by 5%.

In another program getting started in Idaho, nurse care coordinators will advocate for and provide health coaching to patients to help them manage their health conditions. Through the Healthy U CoPartner Program, a joint effort of Regence BlueShield of Idaho and St. Luke's Health System, Regence members who meet specific criteria and agree to enroll in the program will be assigned their own individual nurse care coordinators who will be part of their healthcare team. Coaches will help the patients develop personalized treatment plans, promote lifestyle adjustments, and act as a health coach.

Regence says it has partnered with other providers and employers in Washington and Oregon in for similar initiatives, and one of its pilot programs showed that per-capita spending on healthcare was reduced by 20%, and access to health care increased almost 18%.

Programs like these are often funded by grants—that's the case for the hospital-to-home program in Ohio. In another instance, the California Wellness Foundation awarded a $75,000 grant to allow the nursing students at California State University, Bakersfield to provide free health screenings to uninsured and low-income residents of Kern County. The grant will allow the nursing department's Community Preventive Health Collaborative to operate for three years.

However the programs are funded, though, they all seem to recognize one thing: That the simplest interventions can be some of the most crucial, and nurses are in a perfect position to take the lead.

Source: HealthLeaders Media