Heart Health at Home

Nurses Bring Care Into Seniors’ Homes
by Sara Michael

Visiting an elderly patient at home can reveal the real health habits when it comes to eating well or taking medications—critical truths for managing a chronic illness.

With this in mind, Suburban Hospital nurses conduct regular home visits through the ElderWell program, which targets elderly patients with congestive heart failure and diabetes associated with cardiovascular disease.

According to Cathy Clark, RN, one of the nurses who runs the program, the patients’ hospital assessments might not show the accurate picture of their situations. “It’s not until you go into their home that you really see how they live,” she said.

ElderWell was launched in 1996 in an effort to reduce the high hospital readmission rates for congestive heart failure patients. Nurses visit patients at least once a month and coordinate care with other providers. The private-pay program, which is not covered by Medicare, costs $200 a month, and 32 patients are currently enrolled.

Do You Know?ElderWell’s nurse care managers ask their patients:

Do you know what congestive heart failure is?
What are the two symptoms of congestive heart failure?
Do you know what medications you take for the condition?
Can you name two things you can do to help prevent CHF or the build-up of fluid?
Do you know when to call the doctor?

The nurse care managers are in the unique position to know the necessary questions to ask and the clinical assessments to perform. They are able to provide education, coordinate care with the provider, and connect patients with resources in the community.

“We aren’t just following the disease, we are following everything that is wrong with this patient,” said Margie Hackett, RN, who also runs the program. “We know CHF is just one of the many things they might have going on.”

Suburban Hospital also provides a related free educational program aimed at chronic-disease management with the goal of reducing 30-day CHF hospital readmissions. That program focuses on education about symptom recognition and management, medication, diet and lifestyle changes, and includes one to three home visits.

ElderWell has certainly proved suc-cessful, by just about every measure: hospital readmissions, length of hospital stay, money spent per hospital admission, as well as mental health and patient satisfaction.

“It does work,” says Clark.