Patients recovering from heart failure need a well-coordinated, communicative team behind them. Altru Health System started a program that uses Epic to facilitate communication between providers, and in the program’s first year, heart failure-related readmissions decreased from 17.2% to 11.9% and eventually reached a low of 3%.
As part of the program, North Dakota-based Altru created care teams for each patient’s recovery including a home health nurse, a pharmacist, a cardiac NP, the patient’s PCP, and a health coach. Providers use In Basket and EpicCare Link to coordinate patients’ plans of care and share up-to-date information with each other.
Altru also focused on how patients communicate with their providers. Patients were encouraged to sign up for and communicate through MyChart, helping them easily let their cardiac NPs know about their needs, concerns, and goals.
“We are committed to reducing readmission rates, and this case demonstrates how using a team approach complemented with technology can result in better outcomes for our patients,” said the program authors.
Altru achieved HIMSS Stage 7 for successes including their cardiac recovery program. Read more from HIMSS.