Today, 5.7 million Americans live with CHF, contributing to $30.7 billion in direct and indirect annual costs to the health care system. The vast majority of patients with CHF are complex, as they have multiple clinical and non-clinical comorbidities that exacerbate CHF symptoms. To manage these high-risk, high-cost patients, providers focused early readmission reduction efforts on the 30 days after hospital discharge. However, a few follow-up phone calls post-discharge don't meaningfully inflect patients' long term stability.
How to build an effective cross-continuum pathway for CHF patients
We need more robust and seamless cross-continuum pathways to effectively engage patients with heart failure. To make headway in reducing 30-day readmission penalties, providers need to set patients up for success in the hospital, support post-acute care (PAC) staff during patients' stays, equip primary care physicians (PCPs) to own ongoing management, and extend remote monitoring services to the home. Here are four cross-continuum imperatives to help you get started:
- Address systemic hospital-based barriers to post-discharge management (e.g., insufficient discharge education, gaps in transition planning).
Start transition planning at patient admission to ensure patients don't face any gaps in care during this fragile period. By using evidence-based risk stratification and patient assessments, inpatient staff can begin to tailor care plans and education techniques to patient need.
- Create a hospital-to-PAC pathway supported by dedicated response teams to extend patient management into post-acute care settings.
To prevent patient readmissions from post-acute care sites, providers can build a preferred PAC network with standardized referral and coordination protocols. Some organizations supplement these protocols by deploying care teams that round on patients during the post-acute stay and through the transition home, assessing patients for clinical and non-clinical risk factors. Specialized care teams can include community paramedics to address patients in crisis, social workers to meet non-clinical needs, care coordinators to smooth transitions, and pharmacists to provide medication reconciliation.
- Outline primary care physician responsibilities across discharge, ongoing management, and specialist referrals.
PCPs and their teams can be tasked with increased CHF management in a resource-efficient way. Non-physician staff in clinics (e.g., advanced care practitioners, community health workers, health coaches) can own key tasks (e.g., patient navigation, social service referrals, behavioral change) that help stabilize patients for the long term. By developing solid coordination protocols with cardiovascular specialists, PCPs are able to escalate patients when acuity rises.
- Equip patients with telehealth and remote patient monitoring capabilities to address real-time clinical escalation and transition to disease self-management.
Although remote patient monitoring (RPM) options can require significant upfront investments, these tools—when executed correctly—can generate positive ROI for provider organizations treating patients with CHF. Many stakeholders recognize the efficacy of RPM as a supplemental tool during patients' initial transition out of the hospital or post-acute care. However, it's also helpful in transitioning the patient from active PCP management to self-management. Providers can review self-reported data (e.g., weight, blood pressure) to ensure patients stay on track as they drive forward with medication plans and adopt tactics for sustaining behavioral change.
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