Implementation of a Postdischarge Virtual Visit and Nurse Follow-up Protocol to Decrease 30-Day Readmission Rates for Patients with Pulmonary Arterial Hypertension
Pulmonary arterial hypertension (PAH) is a rare, chronic disease with no cure. Patients with this disease have high mortality and morbidity, experience frequent hospitalizations, readmissions, and psychosocial burdens, and require a high degree of self-care management skills (Doyle-Cox et al., 2016; Lattimer et al., 2016; McDevitt & Walter, 2019). More than half of PAH patients are hospitalized within the first year following diagnosis, and about 20% are readmitted to the hospital within thirty days of discharge (Bhattacharya et al., 2019: Tonelli, 2020). These patients also have a high symptom burden, and these symptoms significantly affect their physical and mental quality of life (Matura et al., 2016). As the disease progresses, so do the symptoms, leading to an increased need for symptom monitoring and management by the patient and the healthcare team. The Pulmonary Arterial Hypertension Center of Comprehensive Care is an accredited facility that serves approximately 400 PAH patients residing in the gulf south region. Evidence supports a multidisciplinary, multi-pronged, comprehensive care model approach to PAH patients\u27 care as they transition through various settings. This quality improvement project introduces two telehealth interventions to address the critical care needs of this population. The first intervention was a provider-led postdischarge follow-up virtual visit that occurred one week after hospitalization. The second was scheduled nurse-led telephone calls beginning after hospital discharge. These interventions were designed to reduce hospital readmissions for this population, encourage self-care management, and remove barriers to quality healthcare by combining technology with best practice healthcare
