Framing the Issue
- With the arrival of Medicare penalties for avoidable readmissions, many hospitals are focusing on heart failure patients.
- Advances in treatment allow more and more patients to survive heart failure, but when they return home from the hospital, they are at risk for readmission if they fail to follow treatment protocols.
- Hospitals are making sure discharge discussions are better-timed, less rushed and include medication reconciliation.
- Home visits by community health workers supported by RNs provide patients with information and support in managing their disease.
The "stick" of Medicare payment penalties has inspired hospitals to use their people power and information technology creatively to reduce rehospitalizations among heart failure patients.
About 5.7 million Americans have heart failure, and the incidence is expected to grow as baby boomers age, people live longer, and the number of people with heart failure risk factors, such as diabetes and hypertension, rises. Improvement in the treatment of coronary artery disease also plays a role.
"A lot of people used to die immediately when they had a heart attack, and now they can be salvaged but they live with sick hearts and the heart failure typically progresses," says Edwin McGee, M.D., co-leader of Northwestern Memorial Hospital's Center for Heart Failure and surgical director for heart transplantation and mechanical assistance.
The national readmission rate for heart failure among Medicare patients averages 24.7 percent. An analysis posted Feb. 14 by Health Affairs indicates that, in all, the size of the penalties outweighs the revenue generated by an avoidable readmission, notes Edward Winslow, M.D., senior fellow at the suburban Chicago health care consulting and information firm Sg2.
The most frequent target of hospitals' efforts to prevent heart failure readmissions is discharge planning. Many hospitals are focusing on making sure discharges are appropriately timed, less rushed and more thoughtful, and include medication reconciliation, Winslow says.
But hospitals are approaching readmissions a variety of ways. Projects run the gamut from focusing on heart failure patients early in their stay to improving post-discharge care and providing disease management.
"You can't just do acute care anymore," says Michael Dickinson, medical director for heart failure and heart transplant at the Frederik Meijer Heart & Vascular Institute, which is part of nine-hospital Spectrum Health in western Michigan. "If a patient presents and gets hospitalized for heart failure, it's not just good enough to get them feeling better and get them home. It's how we take care of them for that next period of time — certainly for 30 days, but ideally probably out for six months to a year."
Spectrum's success story
Spectrum Health's heart failure program takes a multifaceted approach to reducing readmissions among heart failure patients. One part of the effort is Home to Office, or H2O, a program created after a Lean Six Sigma analysis showed wide variation in patient transition from the hospital to the doctor's office.
The initiative led to a reengineering of the care transitions process with the goal of every heart failure patient being seen in the outpatient setting within two to five days after discharge, Dickinson says. These visits are conducted by a nurse practitioner or physician assistant at the system's outpatient heart failure clinic, which offers comprehensive disease management services by a multidisciplinary team that includes cardiologists who specialize in heart failure.
The program meets its goal more than 90 percent of the time, Dickinson says. That's not easy, given that discharge dates often shift. The employed cardiology practice hired a scheduler whose full-time job is to make outpatient follow-up appointments.
The H2O initiative also upended the old discharge summary process in which it might be a week before the document was typed and mailed out. "We had to create communication documents that were completed at the moment of discharge that would be clear to the provider seeing them in the office so the provider would understand what happened in the hospital, what the concerns are, and what the goals are for that follow-up visit," Dickinson says.
The heart failure team also turned its attention to patients discharged to the system's subacute rehabilitation facility. These patients had higher readmission rates than those discharged home. A meeting with the rehab facility team brought to light two important issues, Dickinson says. One was that subacute rehab is not viewed as a hospitalization; therefore, patients do not get acute care or have frequent visits from physicians. The second was the regulations for subacute rehab were written with patient autonomy in mind, so the staff could not put the patients on the restricted-salt diet necessary for heart failure patients to help prevent fluid retention.
The solution was to train the subacute rehab nurses and patient technicians to coach patients about the disciplines of being a heart failure patient. The daily steps include weighing yourself every morning and contacting your provider if you've gained weight, checking yourself for such symptoms as shortness of breath or ankle or abdominal swelling, making sure you have all your medications, and grading your status on a green, yellow, red scale.
The staff went through the same heart failure education as patients and their families, Dickinson says. Now heart failure patients are flagged as cardiovascular transitions patients. Their weight and blood pressure are checked daily, and the staff grade them per shift on whether their status is green, yellow or red and charts the result. "We created a staff that understands heart failure and is enthusiastic about it," he says. "There is an identity there and some pride that they go above and beyond the usual care in this unit."
Another change is that a cardiologist now visits subacute rehab heart failure patients once a week, and an NP or PA visits another day each week. These providers are able to pick up on any subtle worsening of symptoms the regular staff might miss and adjust patients' medications.
The hospital's observation unit also plays a role in preventing readmissions. Before the unit's creation about two years ago, recently discharged heart failure patients who worried about symptom recurrence would go to the ED, and the ED's default was to admit them. But sometimes these patients don't need to be hospitalized, Dickinson says. Now the unit provides short-term care for heart failure patients who don't meet admissions criteria. "You could bring them in for 24 hours, readjust their medicine, sort out what failed, fix it and get them home."
The observation unit staff are trained in heart failure care, and standard order sets and protocols are in place. Patients benefit from getting immediate care and priority for testing, Dickinson notes. The unit is in a converted hospital ward, so patients have regular rooms and meal service.
Repeat ED visitors are either admitted and put on the heart failure service or referred to the outpatient HF clinic, depending on their condition.
The heart failure team includes a clinical psychologist for patients whose heart failure problems stem from home-life or other issues.
'Suddenly it's real to them'
In Delaware, Christiana Care Health System also takes a multipronged approach to reducing readmissions. "We live and breathe this every single day," says Mitchell Saltzberg, M.D., medical director of the heart failure program.
The HF team has two care navigators — specially trained nurses whose job is to find heart failure patients in the hospital so they can provide education, advocate on their behalf and help them safely transition to the next care setting. The hospital leveraged its IT system to identify which patients have heart failure. Whenever physicians write orders for an IV diuretic, the system asks them to specify whether the diuretic is for the treatment of suspected acute HF. If the answer is yes, the patient is added to the nurses' workflow list.
"We've taken a novel approach in our ability to use IT in that we take an order that a doctor is writing anyway and use it as a message in a bottle to our team," Saltzberg says.
In addition, Saltzberg is involved in a manufacturer-sponsored study aimed at preventing ED visits and hospitalization among patients with implantable cardioverter defibrillators. Lung-fluid volume data collected from patients' ICDs are monitored because an increase is a sign of worsening disease. "We've identified through a lot of other work we've done in research that many of these patients are slowly decompensating for weeks before they come to the hospital, so we're trying to get to the bottom of that," he says.
The results are monitored and shared with patients. "We're using that data as a teaching tool so they can see when they're starting to get sick and as a way to mold behavior," Saltzberg says. The idea is to show patients that when they don't follow their treatment plan, it hurts their health. "The insight patients get from that is really remarkable because suddenly it's real to them," he says. "They can say, 'Wow, I didn't realize that just missing my dose of diurectics for a few days would have that kind of an impact.'"
Bottom-line benefits, and more
Although hospital efforts to cut readmission rates have a cost, the economic benefit far outstrips it, Dickinson says. In some cases, the services are reimbursable. For example, the mid-level providers conducting the post-discharge H2O follow-ups bill for the visits. The service is probably cost-neutral, Dickinson says.
The employed cardiology group as a business unit absorbs the cost of the scheduler and is likely losing money on the cardiology visits to HF patients in the subacute facility, he notes. But Spectrum Health is saving money by avoiding preventable readmissions.
"We understand where the world is going," Dickinson says. "We're not going to be able to continue to make money in acute care [by] hospitalizing people. We need to shift to take care of them. We also do it because it's what our career is dedicated to. You can feel good at night thinking, 'Wow, we've built a system that takes really good care of heart failure patients.'"
— Geri Aston is a contributing editor to H&HN.
Heart Failure Medication advances
Researchers have come out with some interesting findings about existing drugs, and some promising new therapies are in the pipeline.
• Digoxin/digitalis may lower rates of 30-day readmissions by more than one-third, according to research presented at the March American College of Cardiology meeting. If replicated, the findings mean digoxin could be an inexpensive tool to lower rehospitalizations.
• GLP-1 inhibitors, approved as a second-line medication to treat diabetes, also reduce the risk of developing heart failure by 41 percent, concludes research presented at the ACC meeting. The findings are particularly significant because diabetes is one cause of heart failure.
• Spironolactone (Aldactone), already shown to extend the lives of some patients with systolic heart failure, appears to improve the structure and function of the hearts of patients with harder-to-treat diastolic heart failure, found a small study by Austrian researchers. The drug's effectiveness in diastolic HF patients also is being studied in the international TOPCAT trial, sponsored by the National Institutes of Health.
• Omecamtiv mecarbil is designed to directly enhance the interaction of the muscle fibers at the cellular level, says Mitchell Saltzberg, M.D., medical director of the heart failure program at Christiana Care Health System, who is involved in the Amgen-sponsored clinical trial studying the medication. The drug holds out the hope of improved heart muscle function without the same level of toxicity as other drugs.
• Mydicar, a genetically targeted enzyme replacement therapy that aims to improve heart muscle function, is being tested in a clinical trial, dubbed CUPID. The agent uses a harmless virus to deliver the SERCA2a gene, which regulates a protein involved in heart contraction. Mydicar is delivered in a single dose directly to the heart during an outpatient cardiac catheterization procedure.
Left ventricular assist devices
The heart pumps known as left ventricular assist devices have gotten better and smaller in recent years, says Edwin McGee, M.D., co-leader of Northwestern Memorial Hospital's Center for Heart Failure. LVADs keep patients with end-stage heart failure alive while they wait for a heart transplant. When patients' heart failure progresses to a point when they need a pump, their one-year survival typically is about 20 percent, McGee says. With the pump, the survival rate is about 80 percent at one year and 75 percent at two years.
In 2003, the Centers for Medicare & Medicare began covering a HeartMate LVAD as destination therapy for people who aren't transplant candidates, and in 2010, the FDA approved Thoratec's smaller HeartMate II continuous flow LVAD for destination use. FDA approval late last year of the HeartWare LVAD as a bridge to transplant introduces competition into the market. The product is smaller than the HeartMate II and can be implanted near the heart, as opposed to the abdominal cavity. HeartWare is seeking FDA approval as a destination therapy.
Part of the art of keeping patients with LVADs alive is having a dedicated team to educate patients about maintaining the device, to deal with possible device complications, and to help patients when they require hospitalization for a separate medical problem, McGee says. Northwestern has a team of specialized NPs who serve as LVAD coordinators. — Geri Aston
HF by the numbers
• Heart failure is the primary cause of more than 55,000 deaths each year.
• Heart failure was mentioned as a contributing cause in more than 280,000 deaths in 2008.
• About half of people who have heart failure die within 5 years of diagnosis.
• More than 1 in 3 Medicare beneficiaries die within one year of heart failure hospitalization.
• The direct and indirect cost of heart failure costs is an estimated $37.2 billion each year.
Source: Centers for Disease Control and Prevention; "Heart Failure Performance Measurement Set," American College of Cardiology, American Heart Association and American Medical Association, updated May 15, 2012
An article published in the Jan. 29 issue of the Journal of the American College of Cardiology focuses on several issues surrounding heart failure readmissions.
• The immediate post-discharge period is known as the "vulnerable phase." An early post-discharge visit is recommended for all patients, but it is unclear which subset of patients should be targeted and what should be evaluated and/or treated. The majority of studies have focused on fluid management and intensive monitoring strategies, but a more comprehensive approach is needed, write the authors of "Rehospitalization for Heart Failure: Problems and Perspectives."
• Early post-discharge evaluations may occur through multiple avenues, such as a follow-up phone call, visiting nurses, an office visit, telemonitoring and home weight monitoring. "Office visits should further optimize short-term diuretic strategies, reassess and re-evaluate medication regimens, and monitor signs and symptoms of HF."
• The complex medical, social and economic factors contributing to high HF readmission rates require an integrated team approach. The patient, primary care physician, hospital physician, cardiologist, other specialty care physicians, pharmacist, nurse, family, social worker and health educator all provide valuable contributions.
• Current national quality initiatives focus on 30-day readmission rates, but this may be problematic "because risk-adjustment models have poor discrimination and do not take into account the competing risk of mortality." High or stable 30-day readmission rates might reflect successful efforts to drive down post-discharge mortality. Also, readmissions might be influenced, not just by quality of care, but by such factors as social support, geographic location and socioeconomics.