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  1. Schell, Wendy RN, MSN, CCRN


Purpose and Objectives: The purpose of this literature review is to investigate the potential benefit of the discharge navigator, patient education, and discharge planning in prevention of hospital readmissions for heart failure as it relates to case management.


Primary Setting: Applicable to all health care sectors where case management is practiced.


Findings/Conclusions: In the United States, over 50% of hospitalized patients older than 65 years with congestive heart failure are readmitted within 6 months of their hospital discharge. The Patient Protection and Affordable Care Act, commonly called Obamacare, was signed into law in 2010 and effective 2012 the Centers for Medicare and Medicaid Services (CMS) began the Readmissions Reduction Program, which requires the CMS to reduce payments to inpatient prospective payment system hospitals with excess readmissions. An estimated total of 2,217 hospitals across the nation will be penalized a percentage of their base Medicare reimbursements. Provisions of the Affordable Care Act that increase hospital's financial accountability for preventable readmissions have made it imperative to identify interventions that reduce hospital readmissions for patients with heart failure. Current evidence suggests that improving transition of care through intense repetitive education reduces hospital readmissions for heart failure by:


* enhancing the patient experience through effective communication and education,


* ensuring accurate medication reconciliation and follow-up appointments are made, and


* providing good hand-off communication to other care providers improving patient care.



Implications for Case Management Practice: Case managers are faced with an ever-changing health care climate, including the demands of hospital readmission prevention. Because of this, case managers are in a unique position to ensure that the patient has a good understanding of their disease, medications, and follow-up instructions. One of the most effective ways to accomplish this is to be sure that every patient is assessed for discharge planning purposes and receives specific and consistent education throughout the care continuum, including follow-up care.