PURPOSE AND PROGRAM SUMMARY
The rate of hospital discharges to skilled nursing facilities is steadily increasing, specifically for elderly cardiac patients. The American Association of Cardiovascular and Pulmonary Rehabilitation recommend the integration of components for comprehensive cardiac care. The American Heart Association reports that Congestive Heart Failure is the leading cause of hospitalization in people over the age of 65.
Nearly 5 million Americans have heart failure and 1.3 million of those individuals end up being readmitted to the hospital. In fact, heart failure has the highest readmission rate of all chronic disease. Many of the hospitalizations can be prevented through the use of clinical-led-care-coordination programs geared toward educating heart failure patients and their families.
It is the intention of The Glen Healthcare Network to establish a Skilled Nursing Facility Cardiac Care Model that caters to Cardiac Rehabilitation as well as long term cardiac care. Our care will be based on exercise, education and outcomes, to include reduction of re-hospitalizations.
We provide cardiac care to help our residents function at the highest status possible while achieving positive outcomes with limited symptoms. Our residents will benefit from specialized processes and services, tools and equipment as well as an interdisciplinary team with specific training for the conditions that require treating.
CARDIAC PERFORMANCE IMPROVEMENT TEAM
2. Cardiac Clinical Champion
4. Social Worker
5. Registered dietitians
6. Primary Care Physician
CONDITIONS AND DIAGNOSIS
- A recent heart attack
- Angioplasty or stent placement
- Pacemaker placement
- Heart surgery
- Congestive Heart Failure
- Dialysis (these patients have the highest cardiac complications)
NEW LEAF PROGRAM
- Residents will be identified as members requiring cardiac care through the following symptoms:
- Acute agitation and anxiety
- Nighttime shortness of breath
- Light headedness
- Shortness of breath when lying down
- Abdominal symptoms, nausea, pain, decreased appetite and destention.
- Weight gain (fluid retention)
- Residents will be categorized from high to low risk for re-hospitalization
- Facility Cardiac Physician will provide consult on any residents with appropriate cardiac diagnosis.
- Residents at risk will receive:
- Exercise program
- Daily weight to monitor fluid retention and build/up
- EKG Machine
- Telemetry Monitors
- Life Vests
PRE AND POST HEART SURGERY
Refer to Glen Transitional Pathway
CARDIAC MEDICAL DIRECTOR
- Will work closely with assigned Cardiac Clinical Champions on each shift within the facility.
- Collaborate with facility Medical Director regarding Cardiac programming and residents.
- Education and teaching to residents, family and staff.
- Monitor and address co-morbidities; assuring does not result in re-hospitalization.
- Manage the telemetry monitoring of all cardiac / heart failure residents
- Provide lectures and continuing education to facility physicians; staff and consumers in collaboration with Business Development.
- Monitor and evaluate pharmacological treatments of heart failure residents.
- Create and update Cardiac model as healthcare continues to evolve.
- Provide Cardiac consultation to any resident with cardiac related diagnosis.