The award-winning Heart Failure Community Transition Program steps in to help, pairing nursing students with recently discharged chronic heart failure patients. Through partnership with MultiCare Cardiac Services, each nursing student functions as client advocate for an older adult client with the diagnosis of chronic heart failure (CHF). They make home visits twice each semester, with weekly follow-up phone calls. With the support of MultiCare's HF Nurse Educator and HF Nurse Navigator, students work with clients and their families to:
1. Reinforce discharge plans
2. Assist the client to set attainable health goals
3. Identify available community resources
4. Encourage proactive self-care
5. Promote wellness through health prevention behavior
The goal of this program is to reduce mortality, avoid admissions to nursing homes & hospitals, and improve the functional status and general wellbeing of the people they serve. Students begin this collaborative care project during their second semester as nursing students and continue this one-on-one partnership until they graduate. After just two years of amazing effort and dedication on the part of MultiCare Health System’s staff and PLU students and faculty, this program has already significantly reduced hospital readmissions. Patients experience tangible, positive benefits and outcomes. The program continues to receive significant attention since being honored with PLU’s Quigg Award for Excellence in Innovation (December 2009) and MHS’s President’s Award for Excellence in Community Partnerships (January 2010). The students gain clinical expertise in physical assessment of the older CHF client and feel they're making a difference in someone's life; the patients love the visits and support; and Multicare benefits from reduced costs. It's a win-win-win venture for health systems, students, and patients.