The University of Virginia Health System's (UVA) Advanced Heart Failure and Transplant Center integrated its discharge process and its post-acute care program for heart failure patients—with dramatic results for mortality rates, readmission rates, and overall costs, Andis Robeznieks writes for Hospitals & Health Networks.
Streamlining the patient discharge process
By combining its discharge process and its post-acute care program for heart failure, called Heart to Home (H2H), the center aimed to streamline discharge instructions and follow-up care for patients.
Under the integrated program, all of the providers and staff on a patient's care team—including physicians, nurses, case workers, pharmacists, and social workers, among others—meet with each other and then collectively meet with the patient several times during the patient's stay and on the day of discharge. The process, called "Rounding with Heart," enables the care team and patient to get a holistic overview of a patient's condition and situation, Robeznieks writes.
"Before we go into the room, we talk about the plan for the day," Kenneth Bilchick, a heart and vascular specialist and associate professor of medicine at UVA, said. "Then we go into the room, introduce ourselves, discuss the plan and answer any questions." According to Robeznieks, the system enables any potential issues, such as with a patient's insurance coverage or incorrect dosage for prescribed medications, to be identified before the providers meet with the patient.
The center also streamlined its discharge summary for each patient to make it easier to understand. At discharge, a nurse will meet with the patient and a family member to review the discharge instructions together.
Timing follow-up care
The integrated program doesn't stop at discharge, however, Robeznieks writes.
After leaving the hospital, patients are scheduled to visit the H2H clinic between four and seven days following their discharge. During that appointment, the patient will meet with two nurse practitioners who specialize in heart failure and who have consulted with other providers—including social workers, physical therapists, and dieticians—about the case.
The patient receives a physical exam, and reviews their medication and diet with the NPs. According to Robeznieks, the goal of the visits is to identify any minor issues that might snowball into a major issue later, such as a physical change that might necessitate a medication adjustment.
Sula Mazimba, a UVA heart and vascular specialist and assistant professor, said the timing of this follow-up visit is integral. "When patients were discharged from the hospital, it was thought that acute care was resolved, and they just needed follow-up," Mazimba said. "But [patients] can easily fall off the cliff. ... 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."
According to Robeznieks, the program has been successful.
Last year, an observational study published in the Journal of the American College of Cardiology assessed nearly 11,500 heart failure patients treated at UVA between 2010 and 2014, of whom 12.5 percent (about 1,400) were enrolled in the H2H program. According to the study, the 30-day mortality rate for patients enrolled in the H2H program dropped from 12.9 percent to 1.8 percent, while the one-year mortality rate declined from 25.6 percent to 15.5 percent. In addition, the care costs for patients in the program averaged $45,617 over one year, compared with $101,022 for heart failure patients not enrolled in the program.
And according to Bilchick, another study showed that H2H patients have shorter hospital stays during the first 30 days after they are initially admitted than those not in the H2H program "In this analysis," he said, "the associated cost savings from decreased readmission days was greater than the cost of staffing the program.
Reflecting on the program overall, Bilchick added, "It's not a very complicated concept—but very effective though. ... Our program is associated with reduced readmission rates, decreased costs, and improved survival, so we managed to get it right" (Robeznieks, Hospitals & Health Networks, 6/19).
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