scholarly journals Improving Value Through Heart Failure Care Coordination: The Allina Health Experience

2018 ◽  
Vol 2 (2) ◽  
pp. 9-13
Author(s):  
Steven M. Bradley ◽  
Pam Rush ◽  
Kim Wolf ◽  
Amin Rahmatullah ◽  
Robin Braun ◽  
...  
Keyword(s):  
Heart Failure ◽  
Care Coordination ◽  
Management Program ◽  
Care Coordinator ◽  
Post Discharge ◽  
Readmission Rates ◽  
Quality Initiatives ◽  
Nurse Care ◽  
Heart Failure Care ◽  
Manage Care

Reducing readmission following heart failure is emerging as a target of quality initiatives in the Centers for Medicare & Medicaid Services Hospital Readmission Reduction Program. In response to higher readmission rates than desired following heart failure (HF) hospitalization, Allina Health hospital's cardiovascular subspecialty care developed an HF nurse care coordinator program to reduce readmissions. The nurse HF care coordinator serves as the bridge to help manage care following hospital discharge and ensure adherence to protocols developed by the HF management program. This effort was initially developed and implemented at Mercy and Unity Hospital and was associated with a 4.3% reduction in HF readmissions. Subsequent expansion of the HF nurse care coordinator program to United and Abbott Northwestern Hospitals was associated similar reductions in HF readmissions. Concurrently, all-cause mortality at 6 months post-discharge was also significantly lower following implementation of the program (mortality pre-HF care coordinator program 12.6% vs. post-HF care coordinator program 18.8%, P = .047) in propensity matched analysis. The findings of this effort suggest the potential for care coordination programs to improve the care and outcomes of patients with HF.

scholarly journals Heart Failure Care Management Program Utilizing Telehealth Technology Yields Readmission Rates Lower Than the State Averge

2017 ◽  
Vol 23 (8) ◽  
pp. S80
Author(s):  
Mark R. Stampehl ◽  
Stephen Henry Jennison ◽  
Claire Call ◽  
Susan Hickey ◽  
Shantanu Sarkar ◽  
...  
Keyword(s):  
Heart Failure ◽  
Care Management ◽  
Management Program ◽  
The State ◽  
Readmission Rates ◽  
Heart Failure Care ◽  
Care Management Program

15. Heart failure care coordinator improves core measure compliance and readmission rates

Heart & Lung ◽  
2011 ◽  
Vol 40 (4) ◽  
pp. 378 ◽  
Author(s):  
E.K. Caslin ◽  
J. Ioannou ◽  
S. Rotman ◽  
S. Russell ◽  
H. Jones ◽  
...  
Keyword(s):  
Heart Failure ◽  
Care Coordinator ◽  
Readmission Rates ◽  
Heart Failure Care ◽  
Core Measure

scholarly journals Heart Failure Care Coordination Increases Post Discharge 7 and 30 Day Appointment Completion

2017 ◽  
Vol 23 (8) ◽  
pp. S8
Author(s):  
Kimberly D. Bischel ◽  
Antonio L. Perez ◽  
Corinne Bott-Silverman
Keyword(s):  
Heart Failure ◽  
Care Coordination ◽  
Post Discharge ◽  
Heart Failure Care

Abstract 214: Multidisciplinary Approach to Improve Process Measures and Prevent Heart Failure Readmissions

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
George Syros ◽  
Mitesh Kabadi ◽  
Sarah Blanchard ◽  
Kristin Aviles ◽  
Claire Melvin ◽  
...  
Keyword(s):  
Heart Failure ◽  
Performance Measures ◽  
Multidisciplinary Approach ◽  
High Risk Patient ◽  
Care Staff ◽  
Rank Test ◽  
Fluid Restriction ◽  
Post Discharge ◽  
Readmission Rates ◽  
Process Measures

Background: Approximately 5.2 million Americans have heart failure (HF). HF morbidity and mortality is high, and 27% of patients are readmitted at 1 month and 50% at six months. Objective: To determine the effect of a multidisciplinary approach on Hospital Quality Alliance (HQA) performance and 30-day HF readmission rates. Methods: A one year, prospective, observational study on the effect of a multidisciplinary approach on 30-day HF readmissions was performed and compared to the prior year’s readmission rate at a University affiliated community hospital. HF patients were identified by case and unit nurse managers, who also screened for intravenous diuretic use to determine if patients had HF but were admitted under another diagnosis. HF patients were clustered geographically where daily multidisciplinary rounds with the unit nurse and care manager, pharmacist, social worker, nutritionist, medical and nursing staff took place. The goal was to ensure compliance with the established HQA Performance Measures, initiate appropriate discharge planning, and assess functional status. Patients were educated on 2 gram sodium diet, 2 liter fluid restriction, daily weight monitoring, and smoking cessation. Follow-up appointments with their PCP or cardiologist were scheduled. Upon discharge, nursing and medical staff provided medication and home management instructions. The patient’s PCP was called by the attending physician or cardiovascular fellow as well as the Skilled Nurse Facility, Rehabilitation, and Home Care staff, when applicable. Targeted in-home support immediately following discharge from the hospital was provided. High risk patient had an in-home 2-3 day post discharge visit by VNA and a Pharmacist to access their weight, medications, and physical activity progress. Results: During the intervention year, 355 CHF patients were discharged and compared to 318 patients in the year prior. The 30 day readmissions were reduced from 79 (24.8 %) to 64 (18.03%), p = 0.04 by Wilcoxon Signed-Rank Test. The Heart Failure National Inpatient Quality Measures performance increased from 95% ± 3.8% (2010) to 99.6% ± 0.5% (2011) - p = 0.008 . Conclusions: With implementation of penalties by Medicare in 2013 for 30 day HF readmissions, strategies to reduce them are critical. A comprehensive intervention involving multiple specialties and appropriate patients’ disposition can reduce 30-day readmission rates as well as improve Heart Failure National Inpatient Quality Performance Measures. Further evaluation of this treatment approach, including an assessment of cost-effectiveness, is warranted.

Abstract 282: Impact of a Multi-Disciplinary Heart Failure Post-Discharge Management Clinic on Heart Failure Readmission Rates

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
Cynthia Jackevicius ◽  
Noelle de Leon ◽  
Lingyun Lu ◽  
Donald Chang ◽  
Alberta Warner ◽  
...  
Keyword(s):  
Heart Failure ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Control Group ◽  
Post Discharge ◽  
Readmission Rates ◽  
All Cause Mortality ◽  
Clinic Group

Background: Specialized heart failure (HF) clinics have demonstrated significant reduction in readmission rates. We evaluated a new multi-disciplinary HF clinic focused specifically on those recently discharged from a HF hospitalization. Methods: In this retrospective, cohort study, patients discharged with a primary HF diagnosis who attended the HF post-discharge clinic in 2010-11 were compared with historical controls from 2009. Within an average of six clinic visits, patients were seen by a physician assistant, a clinical pharmacist and a nurse case manager, with care overseen by an attending cardiologist. The clinic focused on identification of HF etiology and precipitating factors, medication titration to target doses, patient education, and medication adherence. The primary outcome was 90-day HF readmission, with secondary outcomes of mortality and a composite of 90-day HF readmission and mortality. A Cox proportional hazards model with adjustment for potentially confounding demographic and comorbidity variables was constructed to compare outcomes between groups. Results: Among the 277 patients (144 clinic and 133 control) in the study, 7.6% of patients in the clinic group and 23.3% of patients in the control group were readmitted for HF within 90 days (aHR 0.26; 95%CI=0.13-0.53 p = 0.0003;aRRR=74%; 95%CI= 47%-87%; ARR=15.7%;NNT=7). There were few deaths, but adjusted all-cause mortality was lower in the clinic group. For the composite of 90-day HF readmission and mortality, clinic patients had a lower risk (9.0% vs 28.6%; aHR 0.23; 95%CI=0.12-0.45; p<0.0001; aRRR=77%; 95%CI=55%-88%;ARR=19.6%;NNT=6). Conclusion: The multidisciplinary HF post-discharge clinic was associated with a significant reduction in 90-day HF readmission rates and all-cause mortality.

Abstract P279: Using Systems Redesign to Develop, Implement, and Evaluate the Effectiveness of a Care Transitions and Hypertension Management Program for Veterans With Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jason J Sico ◽  
Laura Burrone ◽  
Manali Phadke ◽  
Jan-Michael Ragunton ◽  
Paul Hurd ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Care Coordination ◽  
Clinical Pharmacy ◽  
Care Transitions ◽  
Management Program ◽  
Healthcare Personnel ◽  
Categorical Variables ◽  
Hypertension Management ◽  
Post Discharge ◽  
Post Stroke

Introduction: Patients are routinely discharged after an ischemic stroke with uncontrolled hypertension; blood pressure (BP) at discharge predicts BP 6-months post-discharge. Hypothesis: Systems Redesign approaches can develop and implement effective interventions using existing infrastructure more efficiently to improve care transitions and hypertension management for Veterans 6-months post-stroke. Methods: Two external facilitators with expertise in clinical stroke care and Systems Redesign conducted a rapid process improvement workshop with local healthcare personnel and hospital leadership within a large VA medical center providing suboptimal post-stroke BP control. The team process mapped out the current state of BP control post-stroke and conceptualized a future state with enhanced care coordination between inpatient and outpatient providers and increased engagement of underutilized talent within clinical pharmacy and telehealth. The CAre Transitions and Hypertension (CATcH) management program was created and implemented. Chart review was conducted to collect data related to BP and healthcare utilization. Categorical variables were examined by calculating frequency distributions and using chi-square or fisher’s exact tests. Results: A total of 76 Veterans were the recipient of the CATcH program. Compared to Veterans admitted in the 6-months prior to program implementation, utilization of clinical pharmacy (68.4% versus 33.3%; P =0.0002) and telehealth services (48.7% versus 4.2%; P <0.0001). CATcH patients were also more likely to return home/home with services than historical controls (86.6% versus 60.4%; P =0.003). Mean (SD) systolic BP reduction from discharge to 6-month follow-up these CATcH patients was 8.9 (5.3) mmHg. Rates of readmission to the hospital and presenting to the emergency room within the 6-months post-discharge period were not significantly different between groups. Conclusions: Systems Redesign could be used retool existing workflow and enhance care coordination and collaboration. Improving processes related to care transitions and post-stroke hypertension management increased the likelihood of returning to home/home with services and BP control for stroke survivors.

Abstract 14996: Healthcare Resource Utilization and Costs in Congestive Heart Failure 90-day Episodes Within the Bundled Payment for Care Initiative (BPCI) Model 2, 2016-2018

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Xian Shen ◽  
Gabriel Sullivan ◽  
Mark Adelsberg ◽  
Martins Francis ◽  
Taylor T Schwartz ◽  
...  
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Hospital Stay ◽  
Hospital Readmission ◽  
Hospital Readmissions ◽  
Angiotensin Receptor ◽  
Post Discharge ◽  
Readmission Rates ◽  
Hospital Readmission Rates ◽  
Initial Hospital

Introduction: Congestive heart failure (HF) is the fourth most commonly selected clinical episode among Model 2 participants of the Medicare Bundled Payments for Care Improvement (BPCI) Initiative. This study describes utilization of pharmacologic therapies, hospital readmission rates, and HF episode costs within the BPCI framework. Methods: The 100% sample of Medicare FFS enrollment/claims were used to identify acute hospital stays with a MS-DRG 291/292/293 between 1JAN2016 and 31DEC2018. A HF episode consisted of the initial hospital stay and all Part A & B covered services up to 90-days post-discharge. Prescription fills for angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNI) during the 90 days post-discharge were captured. Rates of all-cause and HF readmissions were reported per 10,000 episodes during the 30-, 60-, and 90-days post-discharge period. Total episode costs were defined as the sum of Medicare payments for the initial hospital stay plus all Part A & B covered medical services in the 90-day post-discharge. Results: The sample included 634,307 HF episodes. Patients received ARNIs in 3%, ACEIs/ARBs in 45%, and neither in 52% of the episodes, respectively. All-cause hospital readmission rates were 2,503, 4,465, and 6,368 per 10,000 episodes during the 30-, 60-, and 90-day periods. The 30-, 60-, and 90-day HF readmission rates were 958, 1,696, and 2,394 per 10,000 episodes. Total mean 90-day episode cost was $20,122, of which $8,002 was attributable to hospital readmissions. Conclusions: Hospital readmissions are frequent for HF patients and contribute a notable proportion of overall HF BPCI episode costs. BPCI participants may consider improving utilization of guideline directed medical therapies for HF, including ACEIs/ARBs and ARNI, as a strategy for reducing hospital readmissions and associated costs.

scholarly journals Post-discharge Acute Care and Outcomes in the Era of Readmission Reduction

2019 ◽  
Author(s):  
Rohan Khera ◽  
Yongfei Wang ◽  
Susannah M. Bernheim ◽  
Zhenqiu Lin ◽  
Harlan M. Krumholz
Keyword(s):  
Heart Failure ◽  
Emergency Department ◽  
Acute Care ◽  
Care Utilization ◽  
Post Discharge ◽  
Readmission Rates ◽  
Risk Of Death ◽  
Observation Units ◽  
Acute Care Utilization ◽  
Significant Change

ABSTRACTBackgroundWith incentives to reduce readmission rates, there are concerns that patients who need hospitalization after a recent hospital discharge may be denied access, which would increase their risk of mortality.ObjectiveWe determined whether patients with hospitalizations for conditions covered by national readmission programs who received care in emergency department (ED) or observation units but were not hospitalized within 30 days had an increased risk of death. We also evaluated temporal trends in post-discharge acute care utilization in inpatient units, emergency department (ED) and observation units for these patients.Design, Setting, and ParticipantsIn this observational study, national Medicare claims data for 2008-2016, we identified patients ≥65 years hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia, conditions included in the HRRP.Main Outcomes and MeasuresPost-discharge 30-day mortality according to patients’ 30-day acute care utilization. Acute care utilization in inpatient and observation units, and the ED during the 30-day and 31-90-day post-discharge period.ResultsThere were 3,772,924 hospitalizations for HF, 1,570,113 for AMI, and 3,131,162 for pneumonia. The overall post-discharge 30-day mortality was 8.7% for HF, 7.3% for AMI, and 8.4% for pneumonia. Post-discharge mortality increased annually by 0.16% (95% CI, 0.11%, 0.22%) for HF, decreased by 0.15% (95% CI, -0.18%, -0.12%) for AMI, and did not significantly change for pneumonia. Specifically, mortality only increased for HF patients who did not utilize any post-discharge acute care, increasing at a rate of 0.16% per year (95% CI, 0.11%, 0.22%), accounting for 99% of the increase in post-discharge mortality in heart failure. Concurrent with a reduction in 30-day readmission rates, 30-day observation stays and visits to the ED increased across all 3 conditions during and beyond the post-discharge 30-day period. There was no significant change in overall 30-day post-acute care utilization (P-trend >0.05 for all).Conclusions and RelevanceThe only condition with an increasing mortality through the study period was HF; the increase preceded the policy and was not present among those received ED or observation unit care without hospitalization. Overall, during this period, there was not a significant change in the overall 30-day post-discharge acute care utilization.

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