In light of payment innovation and readmission penalties emphasizing care across the continuum, Parkview Heart Institute has made a concerted effort to coordinate care for heart failure patients through a new, multidisciplinary project. The key aim is to reduce readmissions in a simple manner that can be replicated at other campuses and critical access hospitals. The initiative consists of three key phases: improving inpatient care and transitioning the patient post-discharge, optimizing the use of telemanagement to improve cross-continuum care, and working with primary care physicians to prevent care. The three phases are further described below.
Phase I: Providing care across the continuum
The first phase of the heart failure project began approximately 18 months ago and tracked 535 patients. The basis for this first phase is a 13-bed collaborative care unit that collocates care for heart failure patients. Notably, the unit has taken a departure from the traditional “Congestive Heart Failure Unit” nomenclature and has been renamed the “Congestive Heart Treatment Unit” to emphasize health and wellness. Approximately 65-70% of heart failure patients are housed in this unit, and care is coordinated by a nurse practitioner (NP). Three key interventions take place in the unit.
Risk stratification: Parkview developed a homegrown CHF risk stratification tool in March 2010, which the NP uses to assess each patient upon admission to the inpatient Heart Treatment unit. The tool is an amalgamation of VHA guidelines and a review of literature. The model relies on both behavior (e.g., complex social issues, home life) and the patient’s condition to assess risk. Specifically, it includes ten indicators such as family support, complexity of case, renal insufficiency, diabetes, and patient lucidity. The algorithm helps direct the inpatient plan of care and provides the risk of readmission. Therefore, the tool helps right-size LOS goals and balance the risk of return.
Multidisciplinary inpatient care: The interdisciplinary heart failure team consists of nurses, an NP, physicians, a pharmacist, a home health coordinator, and a cardiologist who work together to provide a single care plan. The team rounds on patients together using the care plan described above, and nurses are empowered to lead care delivery. Importantly, the inclusion of the pharmacist and enhanced staff education has placed emphasis on medication reconciliation. Medication management has greatly improved, and standardizing the approach has saved nurses substantial time.
In addition, Parkview is helping heart failure patients with “social networking” to ensure they are sufficiently supported through their disease and to help overcome social deficits. Parkview offers innovative heart failure support groups and education, deploying ipad applications to inform patients of their conditions.
Post-discharge care/home health: Previously, home health was only involved with patients the day before discharge. In the new care delivery model, a home health coordinator is integrated three to four days before patient discharge. The coordinator interfaces with case management and palliative care. The earlier intervention allows the hospital to more accurately assess the needs of patients, provide education, and prepare for post-discharge care needs.
In all, the focus on providing care across the continuum has shown substantial benefits. Heart failure 30-day readmissions were 13% at the end of 2010. By September 2011, readmissions dropped to 4.8%. LOS also declined from 5.7 days in the first quarter of 2010 to 4.9 days in the first quarter of 2011. Finally, mortality of HF patients in the collocated unit was 0% across 2011.
Phase II: Telemanagement
After centering on multidisciplinary inpatient care, Parkview aimed to extend care post-discharge. As such, the hospital invested in Bosch’s Health Buddy System in late 2011 to provide remote management. Health Buddy remotely connects high-risk heart failure patients to caregivers by communicating patient information, assisting with education, and encouraging patient compliance. Using Health Buddy, patients answer a series of questions about their health status. Based on the replies, an algorithm generates either a red, yellow, or green score. Patients receiving a red or yellow indication are considered at high or moderate risk, respectively, and encouraged to contact their health care provider. In addition, an NP interfaces with the Health Buddy System to manage patients’ conditions remotely and provide follow-up phone calls. With telemangement, six potential admissions were averted within 11 days.
Phase III: Enhancing prevention through primary care collaboration
The third phase of the heart failure initiative beginning in early 2012 will be to work with primary care physicians to advance preventive efforts, promote early intervention, and ultimately avoid admissions. Though avoiding admissions and, therefore, the accompanying reimbursement may appear counter-intuitive under fee-for-service, Parkview recognizes that federal payment models will continue to place emphasis on reducing hospital utilization and enhancing prevention. In addition, preventing progression of disease is often the right clinical decision for the patient, underscoring the importance of working closely with primary care.
Because there are many moving parts to providing multidisciplinary heart failure care, a CV coordinator is accountable for integrating quality, tracking data, and rounding on patients. Given the positive early results, Parkview aims to deploy these initiatives to 14 clinics and critical access hospitals in the future. In addition, Parkview is prepared for the Readmissions Reduction Program that will begin in FY 2013 and is well-positioned for the coming era of accountable care.
For additional information on coordinating heart failure care deliver, please see the Cardiovascular Roundtable’s publication Reducing Preventable Readmissions or register to see “Mastering the Care Continuum” in our national meeting series.