Preston Memorial lowered heart failure readmissions to zero by implementing a fitted shoe program.
In 2012, the hospital’s heart failure readmission rate exceeded 22.6 percent, compared to the American Hospital Association’s Hospital Engagement Network (HEN) national rate of 18 percent. Despite the fact that Critical Access Hospitals are not penalized for readmissions, heart failure readmissions became an area of focus for the hospital’s HEN team. Keeping patients with a chronic disease in their home is the right thing to do for the patients and their families.
Initially, our team implemented discharge teaching with “teach back,” made follow up appointments for patients before discharge, completed electronic medication reconciliation and provided written home care instructions including daily weight monitoring using a scale. Despite these interventions, patients were still presenting to the Emergency Department with large, unrecognized weight gain and distress.
Location- Preston County, West Virginia.
Type- Critical Access Hospital.
Number of Beds- 25.
Payer Mix- Predominantly Medicare/Medicaid population (80 percent).
Population Served- Our patient population is low-income, aging, with a high incidence of cardiac disease and diabetes.
Preston Memorial’s Emergency Department has an average of 10,000 annual visits.
What We Tried
In interviewing our readmitted patients, we determined that health care literacy was an issue for heart failure patients. We learned that patients were unable to determine for themselves when they were gaining excess fluid and required diuresis. Some patients lacked scales for daily weight monitoring. Others lacked ability to see or read the scales because of poor eye sight or inability to see over their enlarged abdomen. A number of patients were unable to recognize a weight change from monitoring serial weights because of cognitive decline or poor math skills. All of these patient challenges were resulting in potentially preventable readmissions. We then realized we had to solve a health literacy issue!
Our team brainstormed to identify triggers that would indicate weight gain prior to distress when home diuresis would still be a viable option. We decided to assess pedal edema using structured, formal shoes or “Sunday Shoes” (shoes that patients would typically wear to church on Sundays), something that virtually every patient already owned. We developed a discharge instruction sheet that told patients how to assess their pedal edema daily, beginning with the day they left the hospital when they were at a “dry” weight (patient has finished diuresing down to their ideal condition). If their shoes did not fit that morning like they did on the day they were discharged, they were to notify their family provider for instructions or an urgent visit. The Sunday Shoes Program was born and has been utilized ever since!
Following implementation of the Sunday Shoes Program, our hospital’s 30-day heart failure readmission rate dropped to 0 percent for 2013 and 2014. Analysis of 2015 data is currently underway.
- Know your patients and their barriers. There is no universal solution.
- Consider your population’s health literacy and physical abilities. Use simple solutions that are easily understood by patients with low health literacy and accomplished despite their physical disabilities.
- If you choose to use the Sunday Shoes Program, educate the providers and the providers’ front office staff answering the phones. The first few calls made by patients saying that their Sunday Shoes didn’t fit were answered with “Why are you calling us? Go to Walmart and buy some new ones.”
- Emphasize that Sunday Shoes need to be structured, formal shoes such as wing tips or patent leather pumps that will feel tight when pedal edema is present. The patient cannot use tennis shoes or slippers.