Dignity Health St. John's Hospitals - Heart Failure Program

Overview

St. John’s Regional Medical Center and St. John’s Pleasant Valley Hospital are committed to giving all persons with heart failure within the community, and their family members, the knowledge and support necessary to help them maintain the highest quality of life and reduce their risk of being readmitted to any hospital or emergency department (ED). The Heart Failure (HF) Program provides education for a wide variety of patient needs and is open to all those diagnosed with heart failure. This education is in addition to discharge instructions provided to those admitted in hospital settings. This program provides education, risk assessment and referrals.

The comprehensive HF Program is a multipronged approach: 1) Home health follow-up (when applicable), 2) Cardiac rehab, and 3) Congestive Heart Action Management Program® (CHAMP®). Nurses evaluate HF patients and recommend they participate in one or more of the program’s levels based on each patient’s unique needs. Patients are provided consistent telephone follow-up with education and coaching, thereby decreasing the number of readmissions to all hospitals and reducing resource utilization. In addition, HF program participants are referred to the following free services available to the public through St. John’s: Chronic Disease Self-Management Program, Cholesterol, Diabetes and Healthy Heart educational classes and other programs available based on an individual’s need.

Impact

The success of the HF Program can be demonstrated from 2015 results when 216 community participants were enrolled in just the CHAMP element; 97.4 percent of those participants were neither readmitted to any hospital nor had an ED visit within 90 days of completing the program. St. John’s case managers provided initial evaluation and referral to local county medical facilities (including clinics) when indicated for those participants recruited within St John’s Hospitals. This Chronic Disease Management Program and CHAMP are open to all community members with heart failure, including the poor and underserved (in English and Spanish), at no cost to all participants.

Lessons Learned

As this program continues to be successful, program leaders will continue to provide ongoing education for staff and health care providers about the value of the HF Program. Staff will work with the Mercy Health & Vascular Institute to provide consistent telephone follow-up and education to all patients enrolled in CHAMP. The Cardiovascular team will conduct regular meetings to identify strategies to increase program enrollment. They will continue to identify HF program candidates and refer to the appropriate program level and the Chronic Disease Self-Management Program.

Future Goals

Future goals include improving the health and quality of life of those that suffer from HF, empowering them to better manage their disease and reducing their need to be admitted or readmitted to any hospital or ED. Program leaders also plan to increase enrollment of the underserved through outreach, continue to collaborate with community organizations, and continue to reduce avoidable hospital admissions and readmissions for enrolled participants.

Contact: Deborah Klein
Vice President, Philanthropy
Telephone: 805-988-2635
Email: deborah.klein@dignityhealth.org