Reducing 30-Day Readmissions for Heart Failure Inpatients through Coordinated Care and Post-Acute Follow-Up

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1 A. Describe your organization (e.g., hospital, clinic, location, number of beds, number of providers, specialty focus and/or any other facts you d like us to know, including any hardship such as limitation of resources): Swedish Health Services is the largest nonprofit healthcare provider in the greater Seattle area with five hospital locations in the Puget Sound region. Swedish has 1245 licensed beds with 6,960 medical center employees and 916 physician divisions. In addition, Swedish operates a network of 12 primary care clinics and is a known referral center for the treatment of cancer, cardiac care, high-risk obstetrics, orthopedics, organ transplantation, neuroscience and numerous specialty programs. B. Project Title Reducing 30-Day Readmissions for Heart Failure Inpatients through Coordinated Care and Post-Acute Follow-Up C. Provide a brief summary description (150 words or less this section only) or abstract of your project in layperson s language, including quantitative results and outcomes in the areas of the Three Part Aim. A review of patients with the diagnosis of heart failure who were readmitted within 30 days found that a large portion of patients were not compliant with at least one of the recommended behaviors of HF selfmanagement (e.g. properly using medications, following a low-sodium diet, daily weights). In an effort to reduce preventable 30-day readmissions, a multidisciplinary readmissions committee identified and implemented new processes to improve patient care, safety, and quality of life for HF patients (addendum 1). The strategy is focused on bridging the gap between acute and post-acute healthcare services through standardized education, scheduling follow-up appointments, and follow-up phone calls to patients discharged to their home. Since the implementation of these strategies, the 30-day readmission rate for all HF patients at Swedish-Cherry Hill has reduced from a pre-pilot average (Jul Jun 2011) of 23% to 12.2% in the pilot phase (Jul 2011-Feb 2012). The readmission rate for Medicare fee-for-service HF patients has reduced from 23% to 12.4%. D. 1. Describe gap in care and evidence basis for conducting the project or initiative. (15 points: 1 point = no clear need for improvement and limited evidence to support implementing the initiative; 15 points = well described prior gap in performance and RCT-level evidence supporting the intervention) In 2011, Swedish admitted 441 patients with a primary diagnosis of heart failure, in addition to 1388 patients with a comorbidity of heart failure. Studies estimate that the number of heart failure patients will continue to increase in the coming years. 1 High readmission rates for a growing number of heart failure patients would translate into higher costs for the hospital and potential financial penalties from the upcoming Center for Medicare and Medicaid Service s Hospital Readmission Reduction Program. Lower readmissions could reduce costs and improve patient care and satisfaction through integrated and coordinated health care. The Institute for Healthcare Improvement states, Not only do preventable hospital readmissions create unnecessary frustration for patients, families, and clinicians and staff, but they also are extremely costly to the health care system. In fact, 18% of all Medicare hospitalizations are readmissions within 30 days of a prior discharge, accounting for $15 billion in spending in The revolving door of hospital admissions is the direct result of poorly designed discharge and transition processes." 2 1 Heidenreich, PA et al. Forecasting the Future of Cardiovascular Disease in the United States. Circulation. 2011; 123: Reducing Avoidable Readmissions by Improving Transitions in Care. Institute for Healthcare Improvement

2 From July 2010 to June 2011, the average 30-day readmission rate for HF patients discharged from Swedish-Cherry Hill and readmitted back into a Swedish hospital was 23%. Prior to the pilot, there was little coordination between acute and post-acute care for HF patients. A readmissions multidisciplinary committee discovered that there was a need to strengthen the standards of distributing HF education materials to patients and construct a process to improve early follow-up appointments for discharged HF patients. The committee also found no post-discharge follow-up processes to determine whether HF patients experienced barriers in managing their condition. Additionally, there was no formalized process to track and examine readmission rates and other measure outcomes needed improvement, making it difficult to have a coordinated and informed strategy involving multiple groups across the care continuum. 2. Describe the measures and methods used for collecting data or information. (15 points: 1 point = poorly defined metrics and/or subjective data use only; 15 points = clearly defined process, outcome measures and study design) Patient Quality Outcomes Percentage of patients discharged from Swedish-Cherry Hill with a principle diagnosis of heart failure that returned to a Swedish hospital within 30 days of discharge Heart failure mortality rate of patients admitted into Swedish-Cherry Hill Press Ganey HF patient satisfaction surveys for Swedish-Cherry Hill (addendum 3) Process Evaluation Compliance and resource metrics from the first post-discharge call to HF patients logged by the Swedish nurse conducting the call, and analyzed by a readmissions multidisciplinary committee twice-a-month. The metrics are used to identify trends of what are the more common barriers HF patients are experiencing after they are discharged from the hospital (addendum 2) Analyses of readmitted HF patients discharged from Swedish-Cherry Hill are also reviewed at the readmissions multidisciplinary committee meetings. Chart reviews are conducted by the Swedish HF coordinator and the clinical manager for the Swedish CHAT (Collaborative Health Action Team) program, the resource used for post-discharge calls 3. Summarize any system or process changes made based on data or information collected. (20 points: 1 point = data minimally used to identify or direct changes; 20 points = baseline data and information collected were systematically reviewed and prioritized, and robust, data-supported system or process changes were implemented) Key Process Changes Implemented A multidisciplinary revision of a Swedish-designed heart calendar based on the most current guidelines for heart failure self-management, along with a standard protocol to distribute the calendar to all principal HF patients, is in line with best practices for heart failure education (addendum 1) HF patient barriers identified from readmitted HF patient charts, research on patient readmissions, and the heart calendar were used to develop the standard script for post-discharge calls. The goal was to make education consistent in both acute and post-acute settings and to ask questions that addressed key issues to compliance As HF patients with timely and more consistent follow-up appointments are less likely to be readmitted 3, a protocol for inpatient nurse staff to schedule follow-up appointments for patients prior to discharge was implemented (addendum 1) 3 Gheorghiade, M et al. Heart failure: Early follow-up after hospitalization for heart failure. Nature Reviews Cardiology 2010: 7,

3 Twice-a-month multidisciplinary meetings to review processes and readmissions brought awareness to important resources available to Swedish patients, such as a recently-opened residential clinic where we can refer some of our most at-risk HF patients A readmissions analysis found that approximately 15% of readmitted patients are discharged from a skilled nursing facility. This led to expanding the HF pilot patient scope to include patients discharged to Kline Galland, a skilled nursing facility and Swedish partner. Patients transitioning to their homes from Kline Galland receive post-discharge phone calls, allowing for another opportunity to coordinate care with a post-acute health organization. Analysis of readmissions led to better communication between Swedish HF coordinator and patient care team (e.g. case managers, unit nurses, cardiologists) to address patient needs more quickly Review of first post-discharge phone calls led to providing inexpensive resources and enhancing the current EHR system. Specific process changes include: (1) distributing complimentary scales for patients who could otherwise not afford one, as preliminary data showed approximately 10-20% of patients a month did not have a scale at home; (2) adding several reminders within HF patient electronic records and discharge instructions for nurses to distribute heart calendars, as some patients were stating they did not receive a calendar at discharge; and (3) one-on-one discussions between nurse management and unit nurses to reinforce the importance of distributing heart calendars and scheduling follow-up appointments within 7 days 4. Report evidence of Three Part Aim outcomes following system/process changes (30 points) Better healthcare for patients (quality, safety, experience) (10 points); Better health for populations (10 points); Reduced costs (10 points) Better Healthcare for Patients Lower HF patient mortality rate of 4.5% pre-pilot to 1% in the pilot phase, resulting in lives saved Increased patient satisfaction for HF patients according to Press Ganey vendor surveys (addendum 3) Distribution of resources for HF patients to manage their chronic condition (e.g. scales), as identified from trends from internal analyses of first post-discharge calls and readmitted patients (addendum 2) Earlier assessment of needs at hospitalization through initial identification of HF patients and improved care coordination Better Health for Populations Coordinated acute and post-acute care for an increasingly growing HF patient population that strives for efficiency and consistency across the continuum of care (addendum 1) Reduced 30-day readmissions for all Swedish-Cherry Hill HF patients from a pre-pilot average of 23% to 12.2% in the pilot phase, an indication of improved acute and post-acute care Reduced 30-day readmissions for Medicare FFS Swedish-Cherry Hill HF patients from 23% to 12.4% Reduced Costs Reduced costs from a lower rate of HF 30-day readmission leading to a 45% reduction in overall costs, assuming the HF 30-day readmission rate would stay at 23% without the pilot. 5. Describe innovation: how is this work compelling, new or different? (20 points: 1 point = project is a repeat of a commonly known intervention or effort, e.g., something required by regulation/core measures; 20 points = project uses an innovative idea, approach, method used, etc.) Multidisciplinary collaboration and standardized processes across acute and post-acute health care teams were essential to the success of this program. Creating protocols to distribute the Swedish heart disease 3

4 calendar at the hospital and reinforcing inpatient education through post-discharge calls using a standardized script was in line the pilot s goal of coordinated and consistent care. The pilot also aimed to collaborate with other Swedish programs in developing the pilot protocols, resulting in an efficient use of organizational resources, strong partnerships across the system, and alignment with the upcoming CMS 30-day readmissions rule. For Swedish, providing support and reinforcing education through postdischarge calls and scheduling a follow-up appointment prior to discharge for patients are new concepts, and the success from a simple and clearly-defined pilot process makes this an innovative initiative. Swedish plans to develop similar pilots for other chronic conditions, such as Acute Myocardial Infarction (AMI), to help meet the health needs of other prominent patient populations. 4

5 Addendum 1 Addendum 2 5

6 Addendum 3 Press Ganey Satisfaction Scores PRE-PILOT (JUL10-JUN11) PILOT (JUL11-FEB12) Responses 6 3 Extent ready for discharge Speed of discharge process Instructions care at home Overall discharge process