New Jersey success stories

NJ Local Success Stories
Quality improvement endeavors can often feel overwhelming, but chances are, you can learn from the experiences that another physician, hospital or nursing home has had in a similar situation. Coupled with support from Quality Insights Quality Innovation Network, learning what has worked for others — and what didn't — is a valuable strategic planning component. View local stories about the Everyone with Diabetes Counts (EDC) program

Patient & Family Heart Failure Support Group Leads to Reduced Readmissions

Heart Failure Support GroupTrinitas Regional Medical Center, located in Elizabeth, NJ, has been an active Learning and Action Network (LAN) participant in Quality Insights Quality Innovation Network’s Care Coordination and Medication Safety initiative, as a member of the Central Jersey Community, since 2014. Quality Insights has provided ongoing assistance to Trinitas by developing data collection tools, providing data analysis, and sharing best practices to support Trinitas’ readmission reduction efforts.
In 2016, Trinitas determined that the rate of emergency room visits and readmissions among heart failure patients was extremely alarming. The rate of recidivism among those patients was high, and they further learned that it was correlated with lack of effective communication and the culture of the patients. In an effort to improve care for these patients, the Transitional Care team formed a Heart Failure support group. 
The Transitional Care team at Trinitas Regional Medical Center consists of a Nurse Practitioner (coordinator), Pharmacist, Dietician and a Social Worker. They help with coordination of patients leaving the hospital.
Lucy Ankrah, Transitional Care Coordinator at Trinitas formed the group through selection of heart failure patients from their Electronic Health Record (EHR). Outreach consisted of letters, phone calls, and sometimes home visits after discharge.
The group initially started with heart failure patients but now includes patients and family members with other illnesses or diseases such as diabetes, uncontrolled hypertension, COPD, etc. Consequently, it has become a patient and family advisory group which consists of 33 active members and meets monthly to discuss various topics on health and wellness. The main priority is to discuss their needs and perception about their disease.
Multiple sources have determined that involving patients and family members in the healthcare process can have many positive benefits including better health outcomes, improvements in quality and patient safety, lower costs, reduction in preventable admissions, and more.
“People do well by controlling their own behavior, and therefore through motivation and education from the healthcare team, patients and families have the opportunity to incorporate that education to make better choices,” said Ms. Ankrah. Trinitas recognizes the importance of involving and engaging patients and family members to improve care.
Speakers are invited to present to the patients in person and a dietician provides food demonstrations at each meeting.
Some of the topics discussed in the group include: managing your heart failure, depression, exercise, and “shopping for your heart.”
“The group assists our patients in receiving a better understanding of their disease management and self-care. It also provides information for the patients to make good choices in healthcare,” Ms. Ankrah stated.
nutrition in storeTo promote appropriate and healthy eating, patients were taken to ShopRite and taught how to read food labels. They were then given a gift card to shop healthy and make their own food selections which were later evaluated by the Transitional Care Dietician. If they choose questionable foods that are not healthy for their hearts, they are asked to go back and try again.
The food demonstration is popular amongst the group, along with discussion about depression in heart failure. Depression is something that all of the patients agreed is one of their main concerns. According to a Health Science Journal article[1], “depression is prevalent in patients with heart failure and according to estimates, it ranges from 9 percent to 60 percent depending on the definition of depression.” It is important and beneficial for these patients to learn from one another, and to know they are not going through challenges such as depression, alone.
“If the patient does not feel comfortable discussing with the group, the staff is always available for one on one discussion,” Ms. Ankrah said.
Lipi Soni, the pharmacist at Trinitas, is always present at the meetings and patients often come in with questions about their medications if they are confused or need any assistance.
Trinitas views the patients’ interactions and shared stories with one another as their greatest accomplishment within the group. Additionally, the patients in the group have had an extremely low 30-day readmission rate at 3.03 percent, which is something to be proud of. While not directly comparable, the hospital’s overall readmission rate is 26.29 percent for all Medicare fee-for-service heart failure patients.
Ms. Ankrah hopes that the success of their patient and family advisory group will inspire other health systems to form similar groups and help bridge the gap between health disparities.  
“Through this group, patients should be able to manage their disease well, decrease their emergency room visits, and improve their lifestyle,” Ms. Ankrah said confidently.
Thus, the ultimate goal of the group is to improve the quality of health and life among heart failure patients through education and sharing.
The group at Trinitas continues to meet monthly and incorporate the ideas of the patients and family members into the hospital’s culture. Click here to learn more.
Quality Insights Quality Innovation Network works with facilities like Trinitas Regional Medical Center to improve quality of care and is in the process of recruiting patient and family advisors that want to get involved in the healthcare process. If you want to learn more, visit the Quality Insights website or email Mitzi Vince.

[1] Lefteriotis, C. (December 2013). Depression in Heart Failure patients. “Health Science Journal”. 7(4):349-353.