Setting out a plan to prevent hospitalizations

Dr Mildred Chang and a multi-disciplinary working group at Peace Arch Hospital (PAH) have successfully implemented changes to improve care management of patients with congestive heart failure (CHF), particularly isolated seniors.

Their aim was to prevent Emergency Room (ER) admissions and readmissions due to CHF decompensation following hospitalization. 

Taking action using a population health approach

With Facility Engagement project support, Dr. Chang and the team worked on a process to identify CHF patients upon admission, provide public education materials, and spread knowledge in the community at seniors' facilities. 
 
Partnering with community

They further partnered with the Primary Care Network (PCN) to offer early phone follow-up or home visits by neighbourhood nurses after discharge.  
 
With each CHF discharge, PCN nurses have been following up with a phone call to physicians in the White Rock/ South Surrey area to provide additional support and education. 
 
The approach of community management has shown promising initial results, with impacts being validated.
 

“Through our collaboration with the Primary Care Network, we've witnessed a transformative shift in our approach to managing CHF patients. The dedicated follow-up by PCN nurses post-discharge has not only provided invaluable support and education but has also seen a clear focus on minimizing ER revisits and hospital readmissions. It's a testament to the power of partnership and proactive patient care.” – Bianca Grosu, Project Manager