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This first-of-its-kind program in cardiology is designed to support hospitals in providing personalized services to heart disease patients and help them avoid a quick return to the hospital.
“We are honored to be selected for this important pilot program," said Ileana Piña, associate chief of academic affairs in the Division of Cardiology at Montefiore. " Improving transitions of care for patients with heart disease and reducing readmissions are a constant focus at Montefiore and are a growing area of concern for health care as a whole.”
“The Patient Navigator Program will allow us to support a team of experts focused on these patients and will allow for the appropriate care and education to be offered, thus improving outcomes.” Nearly one in five patients hospitalized with heart attack and one in four patients hospitalized with heart failure are readmitted within 30 days of discharge, often for conditions seemingly unrelated to the original diagnosis. Readmissions can be related to issues like stresses within the hospital, fragility on discharge, lack of understanding of discharge instructions and inability to carry out discharge instructions.
The Patient Navigator Program team consists of a cardiologist, a nurse with heart failure care experience, a rehabilitation professional with exercise therapy experience and a doctor of pharmacy.
The team serves as the patient’s advocate for the totality of the transition of care and aims to discharge patients on a timely basis, identify those who are at high risk for readmission and provide resources to help prevent avoidable readmissions.
The ACC created the Patient Navigator Program to support a team of caregivers at selected hospitals to help patients overcome challenges during their hospital stay and in the weeks following discharge when they are most vulnerable.
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