RIDGEWOOD, N.J. -- It's usually good to be back, except when that 'back' refers to a hospital visit. Unfortunately, almost a quarter of all heart failure patients nationwide who have been admitted to a hospital require readmission within 30 days of discharge.
This stark statistic illustrates the ongoing battle to manage this chronic disease. At Valley Hospital's heart failure program, their Outpatient Transitional Care, was developed to tackle this issue.
“Our goal is to keep heart failure patients functioning in their homes and community and to prevent readmissions,” says Vera Usinowicz, an advanced practice nurse who is certified in heart failure and part of the Outpatient Transitional Care team. “We also work to ensure smooth coordination and transition of care, from hospitalization to home or rehabilitation, then back to their doctors for follow-up.”
Outpatient Transitional Care is a multidisciplinary program that incorporates physicians, surgeons, nurse practitioners, nurses, pharmacists, dietitians, cardiac rehabilitation professionals, case management specialists, respiratory therapists and Valley Home Care staff.
The hope is that by providing seamless transfer of care and effective communication, no patients fall through the cracks. “We can fill those care gaps and help patients manage their symptoms,” says Robin Giordano, a nurse practitioner certified in heart failure who serves as supervisor of the program.
“Most of our patients are elderly and have many other medical problems. We like to use a holistic approach with our heart failure patients,” says Dr. Kariann Abbate, a board-certified cardiologist in advanced heart failure and cardiac transplantation, who joined the program in October 2014.
Adds Usinowicz, “Patient and family education is a huge component of what we do. We incorporate education into every visit. We take a patient and family-centered approach and tailor our treatment plans to each patient’s needs.”
For more information the Outpatient Transitional Care Program, please call 201-447-8018.