Hospital to Home (H2H) Best Practices Webinar – Series I Mary Norine Walsh, MD, FACC, The Care Group, LLC Neal White, MD, FACC, Cardiovascular Consultants Medical Group, Inc. and John Muir Health System Jann Dorman, Kaiser Permanente January 13, 2010
Mary Norine Walsh, MD, FACC Director Heart Failure and Transplantation Program St Vincent Heart Center of Indiana •
•
Dr Walsh has been a cardiologist at The Care Group, LLC for 18 years and she is a Clinical Associate Professor of Medicine at Indiana University School of Medicine. In 1996, she developed CardiAction, a disease management program of risk factor reduction and HF management. She is actively involved in clinical research in heart failure, nuclear cardiology and systems approaches for quality initiatives in the practice setting. Dr Walsh earned both her BA and MD from the University of Minnesota. She completed her internship and residency at the University of Texas Southwestern in Dallas. She completed her cardiology fellowship at Washington University School of Medicine, St. Louis, MO. She previously served as Assistant Professor of Medicine in the Division of Cardiology, as well as Assistant Professor of Radiology at the Hospital of the University of Pennsylvania.
Hospital to Home (H2H) A national quality improvement initiative of the American College of Cardiology and the Institute for Healthcare Improvement
Building on Success ACC’s Door to Balloon: An Alliance for Quality IHI’s 100K Lives & 5M Lives Campaigns
Goal Reduce 30 day, all-cause readmission rates for patients discharged with cardiac conditions by 20 percent by December 2012.
H2H Core Concepts 1. Medication Management Post-Discharge Is the patient familiar and competent with his or her medications and is there access to them?
2. Early Follow-Up Does the patient have a follow up visit scheduled within a week of discharge and is she or he able to get there?
3. Symptom Management Does the patient fully comprehend the signs and symptoms that require medical attention and whom to contact if they occur?
The Problem: What Do We Know about Readmission?
Heart failure 30-day Risk-Standardized Readmission Rate Distribution
Krumholz, H. M. et al. Circ Cardiovasc Qual Outcomes 2009;2:407-413
Heart failure 30-day Risk-Standardized Readmission Weighted Average by Hospital Referral Region
Krumholz, H. M. et al. Circ Cardiovasc Qual Outcomes 2009;2:407-413
“What is needed now is an investment in research that provides insight about how these rates can best be improved. In some cases, such research may involve identifying top performers and investigating how they excel.�
Krumholz, H. M. et al. Circ Cardiovasc Qual Outcomes 2009;2:407-413
Rates of Rehospitalization Within 30 Days after Hospital Discharge
Jencks, S et al. N Eng J Med 2009;360:1418-28
Patients for whom there was no bill for an outpatient physician visit between discharge and hospital readmission
Jencks, S et al. N Eng J Med 2009;360:1418-28
Five lines of evidence suggest that rates of rehospitalization might be reduced 1. Controlled studies have shown that certain interventions at the time of discharge sharply reduce the rates of rehospitalization among patients with heart failure. 2. The absence of a bill for an outpatient physician visit in the case of more than half of the patients with a medical condition who were readmitted within 30 days after discharge suggests a considerable opportunity for improvement. 3. Many patients who are discharged after a surgical procedure may benefit from earlier medical follow-up, since a substantial majority of postsurgical rehospitalizations are for medical conditions. 4. Our estimate that 90% of rehospitalizations within 30 days after discharge are unplanned suggests that rehospitalization is probably not primarily driven either by clinical practices (e.g., staged surgery) that cannot be efficiently rendered in one hospitalization or by profit seeking division of services into multiple hospitalizations. 5. The variation among states and hospitals suggests that improvement on a national scale may be possible, but the data do not show which practices cause the differences or whether the differences are exportable.
What Do the Guidelines Say??
The Hospitalized Patient “Post discharge systems of care, if available, should be used to facilitate the transition to effective outpatient care for patients hospitalized with HF�
Hunt SA, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult
Implementation of Practice Guidelines Class I • Multidisciplinary diseasemanagement programs for patients at high risk for hospital readmission or clinical deterioration are recommended to facilitate the implementation of practice guidelines, to attack different barriers to behavioral change, and to reduce the risk of subsequent hospitalization for HF (Level of Evidence A)
HFSA 2006 Comprehensive Heart Failure Practice Guideline Table 12.3.Treatment Goals for Patients Admitted for ADHF • Improve symptoms, especially congestion and low-output symptoms • Optimize volume status • Identify etiology • Identify precipitating factors • Optimize chronic oral therapy • Minimize side effects • Identify patients who might benefit from revascularization • Educate patients concerning medications and self assessment of HF • Consider and, where possible, initiate a disease management program
HFSA 2006 Comprehensive Heart Failure Practice Guideline Table 8.3 Recommended Components of a HF Disease Management Program
• Comprehensive education and counseling individualized to patient needs • Promotion of self care, including self-adjustment of diuretic therapy in appropriate patients (or with family member/caregiver assistance) • Emphasis on behavioral strategies to increase adherence • Vigilant follow-up after hospital discharge or after periods of instability • Optimization of medical therapy • Increased access to providers • Early attention to signs and symptoms of fluid overload • Assistance with social and financial concerns
Decreasing Heart Failure Readmission: The Evidence
CHF Management Programs: Results at 90 Days Clinical Results
Financial Results
P = 0.04
Conventional Care (n=140)
67%
$5275
Study Treatment (n=142)
54% P = 0.03 42% 29%
$4815 P = 0.01 16% 6%
Survival Without Readmission
At Least 1 Readmission
Rich MW, et al. N Engl J Med. 1995;333(18):1190-1195.
Multiple Readmission
Per-Patient Cost of Care
Randomized Controlled Trials of Disease Management in HF • Decreased hospitalization, but with heterogeneity in results • Improvement in prescription of evidence-based medication • Decreased cost • No difference in mortality • No change in quality of life McAlister Am J Med 2001;110:378 -384
Randomized Controlled Trials of Disease Management in HF What worked: • Multidiciplinary teams • An emphasis on patient education and selfmanagement • Enhanced access to specialized clinics or home visits
“To the extent that they deviate from these recommendations, Other types of programs should include an evaluation of their effectiveness.”
What didn’t work: • Telephone-based systems
McAlister Am J Med 2001;110:378 -384
Effect of Education and Support RCT to assess the impact of education and support intervention on compliance and patient empowerment without a medical management component • 40% reduction in total readmissions • 50% reduction in HF admissions • Cost savings of $7515 per patient Krumholtz et al. J Am Coll Cardiol 2002;39:83-89
Education alone works!
Randomized Controlled Trials of Disease Management in HF 29 trials • 43% reduction in HF hospitalization • If specialized follow-up by a multidisciplinary team or HF clinic was involved, all cause mortality was reduced Crucial elements: • Specially trained HF nurses • Patient education • Ready access to clinicians trained in HF McAlister J Am Coll Cardiol 2004;44:810-819
Comprehensive Discharge Planning With Postdischarge Support for Older Patients With CHF Impact on hospital readmissions: Rich Naylor Rich Oddone Rich Cline Stewart Stewart Jarrasma Serxner Naylor Raunville Blue Krumholz Harrison Kasper Riegel
(1993) (1994) (1995) (1999) (1996) (1998) (1998) (1999) (1999) (1999) (1999) (1999) (2001) (2002) (2002) (2002) (2002)
Overall
(95% CI)
Pooled relative risk 0.74 (0.67, 0.81)
Phillips CO, et al. JAMA. 2004;291(11):1358-1367.
Comprehensive Discharge Planning With Postdischarge Support for Older Patients With CHF • Comprehensive discharge planning plus post discharge support for older (>55 years) patients with CHF resulted in a 25% relative reduction in the risk of readmission
Phillips CO, et al. JAMA. 2004;291(11):1358-1367.
Decreasing Readmission: What Seemed to Work • • • •
A single home visit Home visits +/or frequent telephone contact Extended home care services Patient education
Increased frequency of clinic follow-up alone did not consistently work! Phillips CO, et al. JAMA. 2004;291(11):1358-1367.
Discharge Education Improves Clinical Outcomes in Patients with Chronic Heart Failure Event-free survival defined as time to first hospitalization or death for control (blue) and education (red) subjects
Koelling, T. M. et al. Circulation 2005;111:179-185
Intervention was a 60 minute long teaching session with a nurse educator prior to hospital discharge
Cumulative hazard rate of hospital utilization for 30 days after index hospital discharge
RCT involving nurse and pharmacy management
Jack B W et al. Ann Intern Med 2009;150:178-187
The Trans-European Network-Home-Care Management System (TEN-HMS) Study
Cleland, J. G.F. et al. J Am Coll Cardiol 2005;45:1654-1664
Pts randomized to receive telemonitoring, nurse telephone support or usual care
The Trans-European Network-Home-Care Management System (TENHMS) Study Mortality in each of the randomized groups
telemonitoring
usual care
nurse support
Cleland, J. G.F. et al. J Am Coll Cardiol 2005;45:1654-1664
Adhere Registry Disposition All Enrolled Discharges (n=150,745) October 2001 to December 2004
Hospice/LT Care 15%
Home 62%
Home with Add’l Care 14%
Deceased 4% Inter-hospital Transfer 3% Other/Unknown 2% Outpatient Care <1%
â&#x20AC;&#x153;Although the care that prevents rehospitalization occurs largely outside hospitals, it starts in hospitals.â&#x20AC;?
Jencks, S et al. N Eng J Med 2009;360:1418-28
Do you have any success stories or experiences regarding readmissions or care transitions that you would like to share with the H2H Community? If so, please contact the H2H Team at Hospital2Home@acc.org, and you could be featured on an upcoming webinar or educational session!
Improving Transitions of Care Jann Dorman Senior Director CMI January 13, 2010
Jann Dorman Senior Director, Center for Healthcare Delivery Jann Dorman oversees national work to improve care delivery across Kaiser Permanente. She previously served as director of eldercare for Kaiser Permanente in Northern California. Dorman originally joined KP in 1998 as a practice leader in National Venture Development, where she led business development, strategic investments, and joint venture acquisitions. Prior to joining KP, Ms. Dorman spent three years in health care consulting. She began her career as a clinician, practicing physical therapy for 12 years before leaving her private practice to pursue a business degree. Ms. Dorman holds a bachelor's degree in both Biology and Sociology from the University of California, Berkeley, a master's degree in Physician Therapy from Stanford School of Medicine, and an MBA from the University of California Berkeley. Slide 2
Kaiser Permanente Integrated delivery system Permanente physicians in the hospitals, clinics, skilled nursing facilities Electronic medical record Panel management and proactive primary care Extensive chronic disease management Slide 3
We are struggling to manage the process
It feels like we are catapulting our patients out of the hospital!
Slide 4
12
Improvement Approach ď&#x192;&#x2DC; Improve the care delivery process by: 1. Understanding the member experience of the care process and what their needs are during the process 2. Understanding each clinical intervention required to address the clinical care and member care needs 3. Designing the most efficient, reliable, and effective operations to support the clinical intervention Slide 5
From the patient’s point-of-view I have just been in the hospital –this is what I need The staff understands my individual needs and goals when I get home My care giver is part of the conversations so she knows how to help me when I leave the hospital I understand my medications, how to take them, and why I need them I will see my doctor soon after my hospitalization I know when to call and what phone number to call I know someone will check on me when I am home I know all of the people caring for me talk to each other and plan the best care for me.
Slide 6
Key Components of Good Transitions Old paradigm
Pre-Admission
Admission
Stay
Discharge 30 Days Post
New paradigm Risk Stratification Assessment of Patients Needs at Home Plan of Care Medication Management Follow Up Supportive Services Accountability – Provider, Patient, Caregivers Slide 7
13
A Patientâ&#x20AC;&#x2122;s discharge medications list
Slide 8
36
Follow Up Strategies Hospitalist Telephone Access 0-48hrs Telephone Call within 48 Hrs Redesigned DC Summary and Care Plan PCP Follow Up Appointment (Low Risk 0-14 d, High Risk 0-5 days)
Risk Assessment Unresolved Medical Issues Care Plan Review Medication Review Self Care Review
Slide 9
33
Supportive Services
High Risk Follow Up Home RN Visit Home Medication Review with RN/Pharm D Transitional Case Mgt Palliative Care Slide 10
Thank You
Slide 11
Heart Failure Readmissions and Best Practices to Avoid Them
Neal Neal White White MD MD FACC FACC Cardiovascular Cardiovascular Consultants Consultants Medical Medical Group Group And And
John John Muir Muir Health Health System System
Walnut Walnut Creek, Creek, California California
January 13, 2010
Neal Neal White White MD MD FACC FACC Director Director Heart Heart Failure Failure Program Program John John Muir Muir Health Health ď&#x201A;§
ď&#x201A;§
Dr. White has been a practicing interventional Cardiologist with Cardiovascular Consultants Medical Group in Walnut Creek California since 1989. CCMG has offices in multiple cities in the San Francisco East Bay and has 22 physicians. Since 2007 Dr. White has been the Heart Failure Director at John Muir Health. Dr White has a BS in Biology from the University of Santa Clara. His MD is from the University of Arizona where he completed his Internal Medicine training and then was chief resident. His Cardiology training was at University of California, San Francisco with interventional cardiology training at Sequoia Hospital in Redwood City, CA. He is board certified in Internal Medicine, Cardiology and Interventional Cardiology.
John Muir Health Demographics Walnut Creek Campus
Concord Campus
Beds: 578 +176= 754 (2010) Cardiac Surgery 425 cases (2009) Cath/PCI/EP 3673 procedures HF patients (2008) 1353 visits (in pt, out pt + ER) 22.8% 30d readmits, ALOS 4.9d 82% Medicare
Goals for HF Program in 2008 – 25% reduction in inpatient admissions – 25% reduction in readmissions – 25% reduction in emergency department admissions – Improve… • Medication Management • Follow up Appointments • Symptom Management
HF HF Workflow: Workflow: Diagnosis/Pre-Admission Diagnosis/Pre-Admission
HF HF Workflow: Workflow: ED ED & & Admission Admission
HF HF Workflow: Workflow: Hospitalization Hospitalization
HF HF Workflow: Workflow: Post-Discharge Post-Discharge
Strategies to Accomplish our Goals Medication Management Follow up Appointment Symptom Management New Facilities to Accomplish Goals – Develop Observation Unit-opened 2009 – Develop out patient HF Center-?2010
Strategies to Accomplish our Goals Medication Management Follow up Appointment Symptom Management
Medication Management In Patients – Order sets for admissions – Promoted Guideline adherence – Concurrent Chart Review by Cardiac Educators • HF Indicators • Guidelines • Patient Education Book-deliver and review Out Patients – CTI- Care Transition Interaction – Pharmacy Medication Reconciliation
Follow Up Appointment Challenging – PCP’s and specialists say they can but don’t – Ideal if visit is with someone connected with hospitalization
Out Pt Heart Failure Center will facilitate CTI team makes home visit now 48-72h
Symptom Management In Hospital Cardiac Educators CTI Heart Failure Center HF Binders given to all pts – Developed with • Home Health, Nutrition Services, In/Out pt Physical Therapy and Cardiac Rehab and Pharmacy • All groups teach to the same tool
IAU- Interim Assessment Unit Out Pt Status- within the confines of the Hospital near ER Place where IV meds can be administered Other Diagnoses – Chest Pain, TIA, Syncope, HF Readmissions reduced as pt never admitted in the first place
Heart Failure Center Out pt facility which can bring all aspects of HF care together HF Med Director Oversight RNP’s and PA’s Evidence Based Disease Management Focuses on – Get appt within 48hrs – Medication Reconciliation- RN and Pharmacists – HF Education – Symptom management (evaluation and Treatment) – Financial and social assistance support – 24/7 phone service (with RN’s in IAU on call)
HF Center Pt Visits Assumptions 75% of inpatient, observation and ED HF cases eligible (1014 cases/yr) PCP or specialist can refer patient to clinic when immediate evaluation needed TelAssurance® case managers and home health can refer established clients back to the center HF patients call clinic for advice, questions or change in symptoms
Tactics to Develop HF Center Budget Convince administration of value for investment – Until now they make money on readmits – Like beds full – Now there may be beds for other more profitable pts
Convince PCP/Cardiology they won’t lose pts – Focus on being an adjunct to overall care – Meds won’t be changed without their knowledge/approval
Avoid duplication with other projects/approaches
Multiple Multiple Approaches Approaches for for the the Strategies Strategies to to Accomplish Accomplish our our Goals Goals Medication Management Follow up Appointment Symptom Management
In patient Cardiac Educators Care Transition Interaction-CTI TelAssurance Program Interim Assessment Unit Out Patient HF Center