Lowering Hospital Readmissions Through Peer-to-Peer Coaching

Elizabeth Blanchard Hills, BSN MSJ President, Informed Health SolutionsMedicalResearch.com Interview with:
Elizabeth Blanchard Hills, BSN MSJ
President, Informed Health Solutions

Medical Research: What is your role?

Response: My name is Elizabeth Blanchard Hills, BSN, MSJ.  My company, Informed Health Solutions, currently has the privilege of “transitioning” Dr. Smith’s work into clinical practice.  We have been conducting an on-going pilot project with the University of Kansas Hospital since November 2013, and our results are corroborating the results of Dr. Smith’s randomized clinical trial.  We have renamed SMAC-HF; it is now called CareConnext.

Medical Research: What are the main findings of the study? 

Response: That we could, in fact, significantly lower hospital readmissions among heart failure patients.

Medical Research: What was most surprising about the results? 

Response: We have found several surprises:

  • The importance of managing emotions when managing a chronic disease such as heart failure.
  • Dr. Smith’s randomized clinical trial showed depression puts heart failure patients at risk for readmission; this mirrors what we are now finding in the literature.
  • Helping patients feel emotionally and spiritually better is now a signature piece of CareConnext. We screen for depression using the PHQ9, and watch our patients rebuild hope by regaining a sense of control. We do so by talking frankly and directly about sensitive issues that are often time-consuming to address: end-of-life planning, the loss of independence, or asking family members to participate in a change of diet.
  • The value of peer-to-peer coaching.
  • As nursing professionals, we are hard-wired to teach. Because of the time constraints we face, we too often resort to “lecturing” our patients, leaving us little time to validate our patients’ understanding, or their ability to take positive action.  For example, it is easy to “tell” someone to limit their sodium intake to 2G a day.  But does the patient even understand how to read a food label?   If not, would he or she feel comfortable revealing that?
  • CareConnext provides a safe environment for patients to recognize and overcome knowledge gaps because they rely on one another for real-life strategies and emotional support.
  • Our providers are mostly on “standby,” available to address specific questions or misconceptions that specifically require the expertise of an advanced practice nurse or licensed clinical social worker.
  • Our data holds across varying patient populations.
  • Patients who struggle with literacy or language benefit from our intervention as do patients who are affluent, well-educated and compliant.
  • Our providers enjoy the CareConnext model, too.

Our advance practice nurses are quite talented, and therefore much in demand at the University of Kansas Hospital. They are often recruited for interesting projects always in play at a large academic medical center. They were key members of Dr. Smith’s initial SMAC-HF team, and continue to advance our efforts and advocate for CareConnext.  They tell us CareConnext is professionally rewarding, and a welcome change from the standard, one-on-one office visit.

Medical Research: What should clinicians and patients take away from your report?

Response: This particular patient population requires special expertise to motivate, but will remain engaged if they find something of value.

Initially, only two out of ten patients referred would agree to attend CareConnext. As a small business, this number was unsustainable, so we quickly implemented a data-driven, automated outreach effort. Today, almost six out of every ten patients we contact agrees to attend CareConnext.

Given the initial recruiting challenges, our “drop rate” came as complete surprise:

Almost 90% of the patients who attend their first CareConnext session (we meet weekly for one month) attend all four sessions.

This suggests being “noncompliant” is a convenient label we often misuse with our patients. Heart Failure patients have logical reasons for being skeptical of what they perceive as “yet another doctor’s appointment,” such as a lack of energy.

We have been quite strategic in attempting to meet our patients’ emotional needs. The “clinical stuff” (monitoring fluid volume, especially overload) we offer as part of CareConnext are the ‘greens fees’ we pay so we can address and change patient behavior.  By making patients feel emotionally and spiritually empowered, we help them change the feelings they have and the choices they make.

Medical Research: Where does one go for more information?

Response: Our website is located here: www.informedhealthsolutions.com


To Improve Heart Failure (HF) Self-Management through Patients Group Clinic Appointments

Smith, Carol E. Journal of Cardiac Failure , Volume 20 , Issue 8 , S47


Last Updated on October 7, 2014 by Marie Benz MD FAAD