Home Monitoring for Heart Failure: About TIME

Melissa K. Walton-Shirley, MD; Ileana L. Piña, MD, MPH; Clyde W. Yancy, MD, MSc


October 15, 2013

In This Article

Evidence-Based Guidelines

Dr. Yancy: Just so you know, our most recent guidelines tried to make this easy for the practitioner. We know that everyone has anxiety about readmissions, and so we took an evidence-based approach and said, "The evidence tells us that if you focus on the transition-of-care period -- focus means that the patient is informed, knows who to call, when to call them -- if you require that the patient is seen within 7 days and has telephone follow-up within 1-3 days, we know that will help, and then if you enroll patients who are deemed higher risk in a nurse-directed management program, all of this being evidence based, you will reduce the burden of rehospitalization."

Dr. Piña: [interposing] And those are simple --

Dr. Yancy: So everybody is on the search for the technology, the trick. There is no trick. Transition of care, early follow-up, and get a nurse in the middle -- there it is.

Dr. Piña: And information flow between the time they leave the hospital and the next person who sees them. We have even started having our hospitalists, who normally wash their hands once the patient leaves, remain somehow connected to that patient by checking labs and checking other tests that never get checked because they are done on the day of discharge toward the next visit. This will also squeeze down that time for that next visit because the hospitalists don't want to be involved in the outpatient care.

Dr. Walton-Shirley: There have been some data recently about the importance of continuity of care in taking care of the heart failure patient, and if you have this hospitalist program as it stands in America, there is a huge disconnect between the patient's inpatient care and outpatient follow-up.

Dr. Piña: That is why we have started saying: This is the responsible person, [the one] who is sending the patient home until the next practitioner, whoever it happens to be, whether it is a home nurse or a visiting nurse, has made that next contact.

Dr. Yancy: So coordination of care, I agree, is very important. That may be the next threshold.

A Disease of Great Consequence

But an important point that I really would like to emphasize is that we have to decriminalize rehospitalization for the patient with heart failure.

Dr. Piña: Absolutely.

Dr. Yancy: We have to remember that this is an important disease, a disease with great consequences, and when we overstate the importance of keeping someone out of the hospital, unfortunately, bad outcomes may happen to those patients. So if it is an avoidable hospitalization, absolutely, we need to save resources, improve our systems of care --

Dr. Piña: [interposing] And that is probably the word that is missing, Clyde -- avoidable.

Dr. Yancy: This is a disease that can harm people, and the hospital is where they need to come for relief. That is the safe harbor for our patients, and I don't want to close that harbor down.

Patient Education

Dr. Walton-Shirley: Well, you know, we were having a conversation earlier. I am really concerned that just putting a device in someone is going to replace very important conversations with the patient. Many times, I go to the bedside of a patient who has been readmitted, and no one has ever discussed the need for fluid restriction or for sodium restriction, or [asked] whether they are compliant with their medications -- you know, your basic clinical approach --

Dr. Piña: [interposing] Or the reasons that they are taking the medications. Why do they need them? Why do they need to be continued?

Dr. Yancy: And don't forget to turn that prism on us too. Did we explain to the patient why the medicines were necessary? Did we provide the patient this precise information needed for the follow-up? We end up with a "he said, she said" sort of thing, again because we have turned it into such a bad outcome, and it really should be more of a team approach. I think if we do it that way, it would be much better.


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