1. Executive Summary Problem/Opportunity: Evidence: Baseline Data: Intervention: Results:

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1 A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating best practice across the care continuum to reduce avoidable 30 day readmissions. 1. Executive Summary Problem/Opportunity: Nationally heart failure (HF) continues to be a growing problem. It is the leading cause of Medicare admissions with 6.6 million Americans burdened by this disease. Thirty-day readmissions have reached striking figures with one in four patients being readmitted nationally and similar results in Pennsylvania. Costs of these readmissions have prompted Medicare to initiate penalties to hospitals with higher than expected rates. In 2011, our network readmission rates were higher than expected, highlighting an opportunity to improve our current HF Program. In response, our administration formed a multidisciplinary team to evaluate current practices, identify gaps, and develop strategies to redesign the HF program and improve outcomes. Our goal was to reach top quartile performance. This project would be important to any facility challenged by higher than expected readmission rates. Evidence: This multidisciplinary team conducted a thorough review of current literature to identify best practices. Several models were identified that demonstrated success at improving outcomes and reducing readmissions. All emphasized the importance of improving care transitions, outpatient follow up and care coordination. Next, a needs assessment was performed and revealed multiple opportunities for improvement including: knowledge gaps regarding best practices for patients with HF among physicians, nurses and post discharge facility health care providers; no consistent process for following patients after discharge; inconsistent communication between health care settings; and a need for addressing the needs of more advanced HF patients with regards to symptom management at home. Based on the findings of our literature review and needs assessment, we chose initiatives from several studies for designing a new HF program. Baseline Data: Our baseline data was reviewed for the two previous years prior to the Heart Failure Team being led by to Clinical Nurse Leaders. Baseline readmission rates at our main campus for FY 2010 and FY 2011 were 26.7% (index 1.23) and 26.6% (index 1.23) respectively. Baseline readmission rates for the Network were 24.5 (index 1.15) in FY 2010 and 23.0% (index 1.07) in FY (Figures 1, 2, 3, and 4). Intervention: A new model for the HF program was piloted using the framework of the PDCA methodology in order to integrate best practices into our care for patients with HF. The new HF program was patient centered and focused on a coordinated outpatient approach. The program was led by two dedicated Heart Failure Care Coordinators/Clinical Nurse Leaders (HFCC/CNL). Other additional resources included two midlevel providers who alternate between the inpatient and outpatient settings dedicated to the HF population throughout the care continuum. The key components that were initiated included: timely follow-up appointments with health care provider within 3-7 days after discharge from the hospital; follow-up phone calls hours post-discharge; home health care referrals, tele-health monitoring, palliative care and improved communication between health care settings including assisted living and skilled nursing facilities. Throughout the implementation we continuously reviewed readmission data, evaluated results, identified barriers and realigned our interventions. Based on the observed success at our main campus, the model was expanded network-wide. Results: From the inception of our redesigned HF program, in November of 2011 through the end of FY 2013, we have seen an overall 38.8% reduction in HF readmissions at our main campus and a 34.8% reduction for the network. Since then, we have seen sustained improvements both at the main campus and at the network level through FY 2014 to date. The Network has achieved and sustained top quartile performance as defined by the Premier, Inc. database. Our ability to sustain continued success in reducing readmissions suggests that this program can be utilized as a model for other institutions looking to decrease HF readmissions. 1

2 2. Describe the needs assessment process and/or research conducted prior to implementing the initiative and the results of that needs assessment/research, including evidence and baseline data. Nationally heart failure (HF) continues to be a growing problem. The American Heart Association s 2012 Heart and Stroke statistical update reports that approximately 6.6 million Americans have HF and 670,000 new patients are diagnosed each year. This number is expected to grow by 3 million by 2030, a 25% increase in prevalence from 2010.¹HF is also the leading diagnosis of Medicare patients readmitted to hospitals within 30 days of discharge with a nationally reported rate of almost 25%. As many as 53% of these HF readmissions are estimated to be preventable.² Similar results are reported in Pennsylvania. According to the Pennsylvania Health Care Cost Containment Council, HF had the highest 30-day readmission rate in 2010 at 24.3 % and accounted for 37.7 % of all the readmissions.³ Medicare reports readmissions cost more than 17 billion dollars annually and account for much of the wasteful spending prevalent in their system. Health Care Reform and changes in Medicare reimbursement policies has challenged hospitals and other health care facilities to improve care processes for patients discharged after an acute episode of HF to reduce these costly and often unnecessary readmissions. 4 Our organization is a non-profit, tertiary-care, academic, multi-hospital system in Pennsylvania which offers many medical specialties. A high volume of patients fall into our cardiac service line. Our network admits over 2,000 patients with cardiac diagnoses and for cardiac procedures. Admissions for HF remain the largest sector with annual encounters over Our mission is to provide compassionate, quality and cost-effective health care to residents of the communities we serve. Included in this mission is providing best practices to patients admitted with HF to improve outcomes and reduce avoidable readmissions. An analysis of our readmission rates for HF at our main campus and the network revealed that for FY 2010 and 2011 our rate was higher than expected when compared with data from the Premier, Inc. database. In response to these higher than expected readmission rates, senior administration from the cardiac service line, nursing and quality met to discuss strategies for improvement. A commitment to additional resources was also established based on predicted cost benefit analysis of penalties with reduced reimbursements from Medicare if current readmission rates were not improved. The first step was to conduct a thorough review of the literature in order to identify current best practices recommended to reduce HF readmissions. A review of the current literature identified several models demonstrating success at improving outcomes and reducing readmissions. These included, The Transitional Care Model, Project Boost, Project Red and Transforming Care at the Bedside and Hospital to Home (H2H). 5-9 All emphasized care transitions and the importance of outpatient follow up and care coordination. While no one specific model was chosen, initiatives were taken from several to trial for our new HF program. These initiatives highlight the importance of a multidisciplinary team approach that focus on care across the care continuum. The key components identified include: patient education and self-management; use of teach back in evaluating patient understanding; timely follow-up appointments with a health care provider within 3-7 days after discharge from the hospital; follow-up phone calls to be done hours post discharge; home health care referrals, tele-health monitoring, palliative care and improved communication between health care settings including assisted living and skilled nursing facilities. Recommended HF guidelines from the American College of Cardiology and the American Heart Association (ACC/AHA) were also reviewed and supported the need for a disease management program that involved a multidisciplinary team approach that followed patients beyond the hospital setting. 11 The next step was to perform a needs assessment to evaluate current practices and identify where gaps in best practices existed. This assessment revealed multiple areas for improvement including: knowledge gaps regarding best practices for patients with HF among physicians; nurses and post discharge facility health care workers; no consistent process for following patients after discharge; inconsistent communication between health care settings and a lack of process to address the needs of more advanced HF patients with regards to symptom management at home. 2

3 In light of these findings and based on current best practices identified, a plan was developed to redesign the existing HF program. This program would be managed by two Heart Failure Care Coordinators/Clinical Nurse Leaders (HFCC/CNL) with a focus on post discharge care coordination in the outpatient setting. The CNL is a new graduate nursing role with a focus on quality improvement, inter-professional communication, leadership and evidence based practice. In order to define our goals for this new HF program we analyzed data on past readmission rates from FY 2010 and FY 2011 at our main campus and for the network. Our goal was to improve our readmission rates and reach top quartile performance based on benchmarking from Premier, Inc. This new HF model would be centered on a coordinated outpatient care approach that would include two HFCC/CNLs and two mid-level providers. The HFCC/CNLs would oversee the program and the midlevel providers would alternate between the inpatient and outpatient setting providing dedicated resources to this patient population both during admission and in the outpatient setting. The overall goal of the program would be integrating best practices and care coordination for patients with HF across the care continuum to improve outcomes and reduce avoidable readmissions. 1. American Heart Association. (2011). Heart disease and stroke statistics-2012 update. Circulation, 125(), e2-e220. doi: /cir.obo13e31823ac Jencks, S. F., Williams, M. V., & Coleman, E. A. (2009). Rehospitalization among patients in Medicare fee-for-service program. New England Journal of Medicine, 360, Pennsylvania Health Care Cost Containment Council. (2012). Hospital Readmissions in Pennsylvania News release April 26,2012. Retrieved from 4. U.S Department of Health and Human Services. (2010). Affordable care act. Retrieved from 5. Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, control trial. Journal of the American Geriatric Society, 52, Retrieved from 6. Project Boost. (n.d.) Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E.,...Culpepper, L. (2009). A reengineered hospital discharge program to decrease hospitalizations. Annals of Internal Medicine, 150, Retrieved from 8. Nielsen, G. A., Bartley, A., Coleman, E., Resar, R., Rutherford, P., Souw, D., & Taylor, J. (2008). Transforming care at the bedside how-to guide: Creating an ideal transition home for patients with heart failure. Retrieved from 9. Hospital tohome. (n.d.) Jessup, M., Abraham, W., Casey, D., Feldman, A., Francis, G., Konstam, M.,...Yancy, C. (2009) Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults. Circulation, 119, doi: /circulationaha Identify the steps taken to initiate your effort(s) including strategies, implementation plan, and the interventions. Based on our initial goal to reduce HF readmission rates and reach top quartile performance, a new model for the HF program was piloted utilizing PDCA methodology in order to integrate best practices into our care for patients with HF. PDCA is a successive cycle consisting of Plan, Do, Check, Act steps which begins by implementing small changes and then incorporates increasing knowledge and successes to ultimately achieve later and more targeted effects. Our efforts were as follows: Plan - In order to achieve our goal of reducing avoidable HF readmissions, we initially concentrated our efforts at our main campus and focused on integrating best practices with particular attention to our post discharge processes. More specifically we developed the following: 3

4 Outpatient HF Care Coordinator /Clinical Nurse Leader (HFCC/CNL) role who are responsible for overall HF program processes and monitoring of outcomes HF midlevel provider positions- one inpatient and one outpatient who would rotate to assist in continuity of care and timely post-discharge follow up appointments Scripted post discharge telephone calls utilizing a teach-back style of questioning- one for patients/caregivers discharged to home and one for health care workers at skilled nursing/rehabilitation facilities (SNF/rehab). (Figures 5 and 6). Risk assessment tool (Figure 7). Do - Following processes gleaned in the review of best practices we initially implemented the following: Daily tracking of discharge HF patients by HFCC utilizing daily census and Horizon Enterprise Visibility (HEV) boards remotely hour follow up phone calls utilizing teach back scripting to evaluate gaps in care transitions to home as well as SNF/rehabs. Risk Stratification Tool based on follow up phone call assessment, co-morbidities, number of previous hospital utilization episodes (admit or emergency room) in past year and care transition evaluation Subsequent phone calls weekly or biweekly based on risk stratification HF Hotline or program number given to patients with HF education as a safety net for patients to call with problems or questions 3-7 day follow up appointments with midlevel provider Assistance in making timely appointment with PCP, private cardiologist, or at Clinic for indigent patients Medical staff and resident education and pocket reminder cards to promote best practices, adherence to Core Measures and consistency with documentation Promoting home health care (HHC) services for all eligible patients Tele-monitoring system implemented by our own HHC agency Community SNF/Rehab education programs and stakeholder meetings to improve care transitions Palliative Care Program for patients with HF Administration of IV diuretics in the office setting Check - Throughout our implementation process we continually collected data on readmission rates as well as compliance with best practices (i.e. 3-7 day follow up appointment, HHC services ordered, adherence to Core Measures) and HF patient responses to teach back questions. We thoroughly examined our results, identified barriers, and verified improvement. This involved: Regular audits of follow up phone calls to HF patents discharged to home and to SNF/Rehab Drill down assessment of 30 day readmissions when they occur: interviewing patient/caregiver, assessing gaps in process and providing feedback regarding areas for improvement Monthly HF Task Force meetings: bringing together HF team, representatives from medical staff (hospitalist, cardiology and emergency medicine) nursing and case management to evaluate process implementation and barriers Regular assessment of 30 day readmission rates, with data provided by Premier, Inc. Act- Based on the success we observed with implementation of our HF program at our main campus, we then chose to expand this plan on a broader scale throughout the network. This involved: Creating a HF champion role at each of these campuses who would be responsible for ensuring best practices were implemented and utilized under the direction and support of the HFCC/CNL RNs Expanded education to medical, nursing and case management staff regarding best practices Monthly campus specific HF Task Force meetings 4. Summarize the success of your initiative and provide evidence of sustained improvements. From the inception of our HFCC/CNL led HF program, we noted substantial improvements in our readmission rates at our main campus (Figures 1 and 2). Between FY 2011 and FY 2013, we reduced our readmissions from 4

5 26.6% (index 1.23) to 16.3% (index 0.77), a 38.8% decrease in readmission rates. Moving forward to FYTD 2014, readmission rates through December show a similar result with a readmission rate of 16.6%. We have observed similar results at the network level (Figures 3 and 4). Between FY 2011and FY 2013, there was a 34.8% reduction in 30 day readmissions. The readmission rate for FY 2013 decreased to 15.0% (index 0.72) from 23% (index 1.07) in FY Network readmission data for FY2014 through December show slightly higher, though overall sustained results at 15.4%. The factors that were crucial for the success of our HF program in reducing 30 day readmissions across our network were several-fold: Commitment of administration and nursing leadership to champion a HFCC/CNL nurse driven HF program A focus on the outpatient process and care coordination after discharge Real time drill downs of 30 day readmissions daily with feedback Engagement of medical and nursing staff to promote and sustain best practices 5. Describe the potential ability to replicate your initiative in other organizations that provide the same service or serve the same population. Recent changes from the Affordable Care Act have challenged hospitals to reduce 30 day readmissions for several diagnoses including HF or suffer significant penalties. Attention to care transitions and implementation of chronic disease management programs have been suggested as first step to improving outcomes. The HFCC/CNL role is well aligned to address these challenges to reduce 30 day readmissions and improve the quality of care our patients with HF receive. This CNL led HF program required an initial investment of two cardiology midlevel providers and two CNLs. The cost of these resources is estimated at $367,463 per year. Additionally $22,000 was invested in the purchase of 20 tele-health monitoring systems for use by our home health care agency. Financial data for FY2013 was analyzed for our Network and identified that one HF readmission costs an average of $9,552 including direct and indirect costs. Network data for FY 2013 revealed 57 fewer HF readmissions and a cost savings of approximately $544,464. Cost per admission for FY 2014 is estimated at $10,205. Annualized data for FY 2014 is trending towards an additional 22 fewer readmissions and a further cost saving of $224,510. The combined total savings since implementation of the new HF program is estimated at $768,974 Aside from these salaries, no other expenditures were necessary. For many hospitals and networks, penalties incurred will exceed the cost of these additional resources. Additionally, our Finance department estimated savings of approximately $400,000 in reduced penalties for FY The success of this program in reducing 30 day readmissions well below expected values, combined with increasing penalties from Medicare for those hospitals with higher than the expected readmission rates make an excellent case for initiating this program at other hospitals. Currently, a similar program, for COPD patients is being trialed and preliminary results suggest this program may work well for other chronic diseases. 5

6 Appendix Figure 1. Readmission rates, Main Campus. Achieved an overall 38.8% reduction in readmission rates by FY 2013 and maintaining results. Figure 3. Readmission rates, Network. Achieved an overall 34.8% decrease in readmission rates by FY 2013 and maintaining results. Figure 2. Readmission Index, Main Campus. Premier, Inc. top quartile Figure 4. Readmission Index, Network. Premier, Inc. top quartile

7 Figure 5.Post-discharge phone call progress note, patient at home. Figure 6.Post-discharge phone call progress note, patient at SNF or rehab facility. 7

8 Figure 7. Risk Assessment Tool. 8