The challenge

Anchored by a 600-bed hospital, the Charlottesville-based University of Virginia Health System’s Advanced Heart Failure and Transplant Center sees thousands of patients with heart failure and has performed 300 heart transplants since 1989.

Despite the center’s experience with inpatient management, leaders realized that the period most crucial to their patients’ recovery were the two weeks post-discharge. That led hospital leaders to integrate into the discharge process their “Hospital to Home,” or H2H, program, which helps patients to manage their care during this critical period. The program centers on an in-hospital clinic staffed by nurse practitioners that reviews with patients their post-discharge instructions.

“We were trying to prevent early rehospitalizations and improve the overall outcomes for patients with heart failure,” says Kenneth Bilchick, M.D., a heart and vascular specialist and associate professor of medicine at UVA. Patients sometimes need to have their medications adjusted after discharge, he notes, or they may become confused about which medications to take and at what time, all of which can affect a patient’s recovery and stability.

In addition, “some people may have trouble getting to the pharmacy or … some problems are related to socio-economic status. These are all barriers that could cause hospital readmissions,” says Bilchick. “The impact of social factors on health is significant, and some patients do have difficulty getting their prescribed medications and understanding how to take them,” Bilchick says. “We learned that these are real barriers to patients in our care that we need to address.”

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While UVA worked hard to refine its discharge process and ensure that patients had all the information they needed regarding medications and diet at the time of discharge, it became evident that this information needed to be reinforced after discharge. As they are leaving the hospitals, patients “are not necessarily in a very good frame of mind to recollect the information later,” notes Sula Mazimba, M.D., a UVA heart and vascular specialist and UVA assistant professor.

Discharge instructions

In an effort to reduce readmissions, a patient’s entire care team — doctors, nurses, floor managers, case workers, discharge managers, pharmacists, residents and social workers — visits on the morning of discharge, as on other mornings of the patient's stay, in a program they call “Rounding with Heart.” By having different disciplines round together, the team can provide a holistic assessment of the patient’s condition and circumstances. A pharmacist, for example, may catch the risk of a counterindication or a wrong dosage on the spot, or a case worker may discover a social or insurance issue.

“Before we go into the room, we talk about the plan for the day,” Bilchick says. “Then we go into the room, introduce ourselves, discuss the plan and answer any questions.”

How it works

UVA strives to provide a “very clean” discharge summary that patients can understand easily, with no ambiguities. The discharge nurse reviews discharge instructions with the patient in the presence of a family member.

As part of the H2H program, patients are scheduled to visit UVA’s H2H clinic between four and seven days post-discharge. Patients come in for an hour-long appointment to the clinic run by two full-time nurse practitioners who specialize in heart failure. The nurse practitioners also consult on cases with dietitians, genetic counselors, physical and occupational therapists, and social workers.

During the visit, nurse practitioners can detect any physical changes that may require medication adjustments in time to stop small problems from becoming big ones.

“When patients were discharged from the hospital, it was thought that acute care was resolved, and they just needed follow-up,” Mazimba says. Traditionally, this was occasional follow-up, generally one month after discharge. "But [patients] can easily fall off the cliff," Mazimba says. "Seeing them sooner rather than later has been the key. If anything is going to happen, it will be in the two weeks after discharge.” 

At the clinic, patients get a physical exam and review their medications and dietary restrictions with the NP. Heart failure is a chronic condition that you really need to manage to put patients on a “trajectory of healing,” says Mazimba. The program aims to keep patients from going “back to square one with fluid overload,” he says.

"The nurse practitioners catch many things [such as] meds the patients are not supposed to be taking,” Mazimba says. “They talk about what they’re supposed to be eating and not supposed to be eating.”

“It’s not a very complicated concept — but very effective though,” Bilchick says. “Our program is associated with reduced readmission rates, decreased costs and improved survival, so we managed to get it right.”

Reported outcomes

Results of the program were reported last April in the Journal of the American College of Cardiology in an observational study that looked at 11,490 UVA patients with heart failure between 2010 and 2014, including 1,385 (12.5 percent) who were enrolled in the H2H program.

The program was found to reduce mortality at 30 days to 1.8 percent, down from 12.9 percent, and at one year to 15.5 percent, down from 25.6 percent. The average cost of care over the year after was $45,617 for the H2H patients and $101,022 for those not in the program.

“Considering the large number of patients with heart failure, these significant cost savings with our H2H program have important implications for reducing health care expenditures,” the report concluded.

Lessons learned

Bilchick cited another study that analyzed 7,000 heart failure hospitalizations at UVA in which preliminary data suggest that H2H patients spend fewer days in the hospital during the first 30 days after their original admission than non-H2H pateints. “In this analysis,” says Bilchick, “the associated cost savings from decreased readmission days was greater than the cost of staffing the program.”