Martha Green didn't know what to think one Sunday morning last December when she felt extremely short of breath as she walked into church. She decided to get checked out at the emergency room at CHI Memorial Hospital in Chattanooga, Tennessee.

After a few days of tests, doctors diagnosed the retired nurse with heart failure. Her heart was not pumping adequately to serve her body. She was shocked, and scared. She went from taking almost no daily medications to taking eight.

"It was very overwhelming," she said. "To me as a nurse, or to anybody, really, when you get anything to do with the heart, that is a frightening thing. Very frightening. And I'm a very strong person and take everything in stride ordinarily. At one point, I even became tearful, because I thought this is a lot more than I bargained for."

Green is more confident now, and healthier, because she is a part of The Chattanooga Heart Institute's heart failure readmission reduction program. The heart institute is part of CHI Memorial Hospital, a member of CommonSpirit Health.

The hospital educates its patients with heart failure on their diagnosis and treatment, following up with regular phone calls and helping them schedule appointments. Staff members help arrange transportation to those appointments and assist patients in finding the lowest prices on medications. Specialists and departments in the hospital communicate with one another about cardiac patients, and a pharmacist is dedicated to looking over the charts of patients with heart failure, ready to offer feedback.

"It seems intuitive, doesn't it?" said Dr. Allen Atchley, a cardiologist and founder of the program. "It gives you a hint as to how complex patients are, how complex hospitals and hospital systems are, and how much effort it really does take to provide the care that patients need, and to coordinate that care and focus on education and communication."

Dr. Aditya Mandawat, the current director, said the program takes a village. "I'd love to tell you that there's one thing we did, or one thing that was rated critical, but the honest answer is there were a lot of people really important in getting our heart failure admissions where they are, and a lot of different pieces that fell into place," he said, "and we still continue to work on and iterate on and try to bring our heart failure readmissions down."

The program follows about 20 to 25 patients on their daily schedule, with about 80 to 100 in the program in any given month.

When the program started in 2012, the national average for heart failure readmission within 30 days was 22-23%. CHI Memorial's rate was 16.44%. Though clinicians knew the hospital was below the national average, they set a program goal of 15%. By the end of 2013, the readmission rate was 12.59%. In 2015, it dipped to 8.92%.

By 2024, the hospital's readmission rate had ticked up to 17.36%, still lower than the national average of 19.8%. The hospital attributes the rate increase partly to a rise in the number of higher-risk patients.

"What we've seen over the last five years is that patients have gotten sicker, but they're also living longer," said Mandawat. "That's not a unique phenomenon. A lot of it is just we've gotten better at taking care of sicker patients."

Tackling the problem
Atchley said that before the program, departments involved in the care of patients with heart failure operated in silos and there were presumptions about whether patients understood how and when to take medications, how to care for themselves, and whether they could make and get to follow-up appointments.

A multidisciplinary team of two nurses and a case manager worked with Atchley to develop the program. They looked at all the departments and people involved in caring for a heart patient: cardiologists, internal medicine, specialists, outpatient primary care, inpatient care, coding and documentation. They improved communication to get on the same page about the patients with heart failure.

They also had to identify the heart patients and their needs and learn more about their geographic limitations and expectations. Many patients are older, with multiple medical problems, rely on Medicare, and live within 30-40 miles of the hospital. Many live in skilled nursing and rehabilitation facilities.

Patient education
As part of the program, nurse educators meet initially with patients in the hospital, give them a packet of information and follow up with phone calls. They get in touch with the extended-care facilities where some patients live. They teach patients about heart failure and the things they could do on their own to improve their health, such as making diet changes, and when and how to take medications. They make sure the patients set up follow-up appointments with doctors and at the cardiac rehabilitation center. They arrange rides if needed.

As the heart failure program coordinator, nurse Emily Drake has two roles: She sees patients, educates them, and makes follow-up calls and she scours hospital data to see if she can find ways to improve care.

"The data tells us where we need to improve," Drake said. "But the actual working with the patient is where I get my joy."

The program also includes Alicia Johnson as the cardiac case manager and nurses Megan Anderson and Chelsey Tyler as patient educators.

"The beauty of it is it allows (patients) a comfort level with us, and then they get to ask all the questions they want," said Drake. "They don't feel put off, like I've got to hurry and get to the next patient. I think that's one of the beautiful things about what we do here is that we can spend that time with them and/or their family members if they need it."

A personal touch
Mandawat also loves working with patients and knows that each conversation about their priorities and quality of life will be different. "Some people want to go fishing, and other people go to Italy," he said. "That's what makes heart failure sort of interesting and special. Every case is different, and everyone has different expectations of what they want their life to look like."

Atchley said the program adheres to the hospital's goal of providing excellent patient care "but within our mission of the hospital, which is to do so with reverence, integrity and compassion. And I think if you do that, the patients always will do better."

Green, the patient, was at first reluctant to talk to her friends about her heart failure diagnosis, because she didn't want them to worry or think of her as frail. "But now, if I hear of anybody who has heart problems, I tell them all the things that are available, that even as a nurse I didn't know was available because I didn't need it," she said.

She's doing well and attends cardiac rehabilitation twice a week. She's grateful that the program helped her get the best deal on her medication.

She talks to Drake nearly every day. "We don't have to, but if I have a question of any sort, she's there, Johnny on the spot," said Green. "That is a wonderful thing."