The medical center is one of 35 nationwide in the ACC’s Patient Navigator Program that launched this year to apply a team-based approach for keeping patients at home and healthy after hospital discharge. VCU’s Pauley Heart Center hosted a kickoff event Oct. 24 of the program’s beginning at VCU Medical Center.
The VCU initiative will be unique in that group clinics will be developed to educate patients on self-care of complex diseases, such as coronary artery disease and congestive heart failure. Patients will interact with multidisciplinary care teams, including nutritionists, nurses, social workers and pharmacists, all who are specialized in heart failure.
“We are thrilled to be starting this program with the support of the VCU Medical Center leadership and the ACC,” said Keyur Shah, M.D., assistant professor in the VCU Pauley Heart Center and a heart failure specialist. “This is a program that directly interfaces with and improves patient care, and will focus on the high-risk, early post-hospital discharge.”
In the U.S., nearly one in five patients hospitalized with heart attack and one in four patients hospitalized with heart failure are readmitted within 30 days of discharge, often for conditions seemingly unrelated to the original diagnosis. Readmissions can be related to issues such as stresses within the hospital, fragility on discharge, lack of understanding of discharge instructions and inability to carry out discharge instructions.
“An increased focus on education, nutrition and communication with patients when they are at a very vulnerable point in their care is critical,” said Michael Kontos, M.D., director of the VCU Pauley Heart Center’s Coronary Intensive Care Unit. “We believe the additional support this program offers will assist us in these efforts, and substantially improve patient care and reduce readmissions.”
With the help of a $10 million sponsorship from AstraZeneca, the ACC’s Patient Navigator Program will allow the creation of support teams of caregivers to help patients overcome challenges during their hospital stay and in the weeks following discharge when they are most vulnerable. The ultimate goal will be to create a program that supports a culture of patient-centered care that can be implemented in other hospitals.
Hospitals that participate in the ACC’s National Cardiovascular Data Registry, a cardiovascular data repository, and the Hospital to Home (H2H) Initiative are eligible to participate. The program combines the power of the registry’s infrastructure with the improvement strategies used in H2H.