title: Tailoring your heart failure project for success in rural areas.
abstract: OBJECTIVE
  The purpose of this project was to decrease heart failure (HF) readmissions in a rural community by redesigning the inpatient education model.
  
  
  METHODS
  An integrated plan of care (ICP) was developed using 6 interventions, tailored to the needs of patients in this community. The interventions in this quality improvement project included (1) upgraded HF education for patients and families using teach-back methodology, (2) a discharge HF packet with survival skills, (3) nutrition education, (4) case management, (5) making appointments for patients with their primary care provider for a visit 5 to 7 days postdischarge and with their cardiologist for 2 weeks after discharge, and (6) a follow-up phone call to each patient within 48 hours postdischarge.
  
  
  RESULTS
  Readmission rates decreased 36.9% with implementation of the ICP. Patients without the discharge teaching/packet were almost 7 times more likely to be readmitted.
  
  
  CONCLUSIONS
  The IPC was effective in decreasing HF readmissions.
  
  
  CONCLUSIONS
  These findings suggest that organizations should focus on developing their discharge teaching methods and ICP to meet the needs of their community. Projects such as these can be used for many chronic disease processes, not only HF.
authors.affiliation: Medical Associates of Central Virginia, Appomattox (Ms Vesterlund); Duke University School of Nursing, Durham, North Carolina (Drs Granger and Oermann); Medical Director Hospitalist Service, Centra Southside Community Hospital, Farmville, Virginia (Dr Thompson); and Medical Associates of Central Virginia, Lynchburg (Dr Coggin).
authors.forename: Martha
authors.initials: M
authors.lastname: Vesterlund
authors.forename: Bradi
authors.initials: B
authors.lastname: Granger
authors.forename: Terry J
authors.initials: TJ
authors.lastname: Thompson
authors.forename: Chuck
authors.initials: C
authors.lastname: Coggin
authors.forename: Marilyn H
authors.initials: MH
authors.lastname: Oermann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006764:Hospitals, Community; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008484:Medicaid / Q000191:economics; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D010347:Patient Care Planning / Q000458:organization & administration*; D010351:Patient Discharge / Q000706:statistics & numerical data; D010353:Patient Education as Topic; D010359:Patient Readmission / Q000706:statistics & numerical data*; D058996:Quality Improvement / Q000458:organization & administration*; D018570:Risk Assessment; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States; D014768:Virginia