Breaking the Cycle Reducing Rehospitalization for CHF Patients After Discharge From Hospital

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Breaking the CycleReducing Rehospitalization for
CHF Patients After Discharge From Hospital

• Steven C. Bergeson M.D. William Dickey M.D.
• Allina Hospitals and ClinicsMinneapolis,
  Minnesota

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Disclosures

• Steven C. Bergeson M.D.,
• Medical Director Quality for Allina Hospitals
  Clinics NONE
• William Dickey M.D.
• Director of Quality and Patient Safety at Abbott
  Northwestern Hospital - NONE

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Abbott Northwestern HospitalPercent of Unique HF
Patients That Had One or More Readmissions Within
30 Days For Any Readmit Diagnosis
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Abbott Northwestern HospitalPercent of Unique HF
Patients With One or More Inpatient
Readmission(s) Within 30 Days to Any Allina
Hospital for Any Diagnosis, Elective Readmissions
Removed
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Abbott Northwestern HF Inpatient Mortality
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Learning Objectives

• Identify 4 high leverage opportunities that have
  been demonstrated to ease the transition from
  hospital to home care for patients with heart
  failure
• Discuss the successes and challenges of improving
  the process of care transitions and chronic
  outpatient care
• Leave equipped with an understanding of what is
  required to apply these change concepts to your
  local practice environment

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Question

• What percent of CMS HF patients are readmitted
  within 30 days of discharge?
• 19.6
• 22.5
• 26.9
• Jencks et al NEJM 2009
• Anderson et al NEJM 1984

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The Allina Medical Clinic (AMC) An AMGA member
group practice 150 Hospitalists 400 primary
care physicians 175 specialists 170 advanced
practice clinicians (NPs PAs) Two million
visits annually. 44 locations Allina Hospitals
and Clinics 11 Hospitals, 22,000 employees, Home
Care, Palliative and Hospice Care, Pharmacies
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CMS Core Measures Optimal CareScores for Heart
Failure (HF)
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Patients
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ABBOTT
MERCY
UNITED
UNITY
Allina-Metros
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Problem Statement

• You are a leader of a large hospitalist group
  and are proud your hospital has consistently
  performed in the Top Tier of hospitals for
  quality on CMS Core Measures and the role your
  group has played in maintaining this level of
  performance. However, you have just received data
  that demonstrates mediocre results for rates of
  rehospitalization for your patients with CHF
  within 30 days of discharge.
• Where do you start, what does the literature say?
• What systems of care will you need to address?
• Who should you get on the team? How to start?
• What difficulties will you encounter as you do
  this work?

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CMS 30-Day Heart Failure Risk-Standardized
Readmission Rate (RSRR) 2006
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Rates of CMS Rehospitalization Within30 Days
after Hospital Discharge
Jencks SF et al. N Engl J Med 20093601418-1428
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What does the literature say?

• There is potential to improve and it has been
  known for a long time
• Rich et al, NEJM. 1995. 333, 1190-1195.
• Randomized controlled trial of intervention in
  282 elderly patients hospitalized with heart
  failure

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Rich Study

• 5 Interventions
• Intensive CHF education
• Consultation with social service about discharge
• Individual dietary instruction
• Analysis of medications by geriatric cardiologist
  with intent of simplification and elimination of
  unnecessary medications
• Intensive follow-up at discharge

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Rich Study

• Endpoint improved survival without readmission
  at 90 days did not make significance 64.1
  treatment vs. 53.6 control (P0.09)
• Readmissions
• 42 control
• 28.9 treatment (P0.03)
• Multiple readmissions
• 16.4 control
• 6.3 treatment (P0.01)

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Potential Targets

• Medications and Doses
• ACE inhibitors (or ARBs) in systolic dysfunction
  reduce symptoms and mortalitymultiple studies
• Beta blockers reduce mortality in systolic
  dysfunctionmultiple studies
• Modest evidence that titration of ACE inhibitors
  to target may have added benefit over ACE
  inhibitor at low dose in systolic dysfunction.

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Potential Targets

• Education and Self Management Support
• Krumholz et al JACC. 2002. 39, 83-89.
• 88 patients 44 treatment patients got one hour
  in depth education followed by weekly phone calls
  for 4 weeks, biweekly for 8 weeks then monthly
  for a year
• Readmissions or death in one year 81.8 control
  56.8 treatment (P0.01)
• Readmissions alone reduced but did not make
  statistical significance.

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Potential Targets

• Medication reconciliation
• Coleman et al 2005 Arch Internal Med.Elderly
  patient with a medication discrepancy is twice as
  likely to face readmission
• Our own data 1 in 3 heart failure patients were
  not taking their medications according to
  instructions

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Question

• What percent of CMS HF patients who are
  readmitted within 30 days of DC have not seen an
  outpatient clinician since discharge?
• 30
• 40
• 50
• None of the above?
• Jencks, NEJM, April 2009

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Question

• What percent of CMS HF patients who are
  readmitted within 30 days of DC are
  rehospitalized within 7 days?
• 20
• 30
• 40
• 50
• Jencks, personal communication 2007

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HF Time to Rehospitalization (ANW)July 1, 2006
June 30, 2007
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Potential Targets

• Early Follow-up Visit
• Our own data Of patients admitted within 30
  days, 40 admitted in first week
• Subsequent data from the Jencks study of Medicare
  Claims. NEJM. 2009
• 26.9 of CHF patient readmitted within30 days
• 52 of those did not have a bill submitted for a
  physician visit in the interval between discharge
  and readmission

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Summary of Literature Supports

• Multifactorial interventions
• Getting patients on right meds with plans for
  optimization
• Education and self management support
• Getting medications right at transition
• Early follow-up

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Question

• What is the most common reason for
• readmission when discharged with a
• principal diagnosis of HF?
• HF
• Pneumonia
• Renal Failure
• Nutrition/Metabolic
• Other AMI, COPD, Arrhythmias, etc.

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Care Across the System

• Optimal Hospital Care
• Optimal Discharge
• Optimal Transition
• Optimal Outpatient Care

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The Must Haves

• Follow-up appointments within3-5 days
• Rapid flow of information
• Help patients manage their condition - Self
  management support
• Transition support

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Follow-up appointments within 3-5 days

• How do we know it will be a good
• visit? (RB)
• Inpatient care team decidesPrimary vs.
  Cardiology HF Clinic in 3-5 days
• With usual clinician not any available clinician
• Not a double booked appointment
• Information for OP clinician availablewith a
  plan
• Script the OP visit and develop toolsto help

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Question

• What percent of clinicians have a DC
• summary by the time they see a patient
• one week post discharge from hospital?
• 15
• 20
• 25
• 30
• Kripalani, Review, JAMA, Feb. 2007

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Rapid Flow of Information

• Summaries done the day of DC
• Accurate medication reconciliation
• After Hospital Recommendations a 30 day plan
  for the next clinician

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Help Patients Manage Their ConditionSelf
Management Support

• Red Yellow Green self management tool when
  to call for help
• Who to call
• Purpose of meds
• Teach Back methodology

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Does the information we giveto patients help
them?
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Transition Support

• RN phone calls 24 hours after DC
• Home Visits for high risk
• Care Management for the highest risk

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OPTIMALIN-PATIENT CARE
OPTIMAL OUTPATIENT CARE
OPTIMAL DISCHARGE
OPTIMAL TRANSITION

• Phone call to patients 24 hours after D/C
• Home visits with Home Care RN to patients at risk
  based on call
• Self Management Support (SMS) Patient uses
  Red-Yellow-Green tool to Self Manage
• Scales available for patients
• Clinic appointment 3-5 days after D/C

• ID all HF patients real time (i.e. BNP
  Workbench Report)
• All Patients who need a cardiologist see one See
  the right cardiologist
• Provide Self-Management Support (SMS)- using
  Red-Yellow-Green tool to all patients
• Identify all patients needing home care

• Use HF Discharge order set
• Generate a 30 day plan for next level of care
• Set up appointment for 3-5 days in clinic after
  D/C (HF Visit)
• Make it clear to all who the patient is to call
  for problems
• Reconcile Medications correctly

• Have an appointment available in clinic for the
  3-5 day follow-up
• All meds reviewed and verified (Med
  Reconciliation)
• Follow the 30 day plan started in hospital
• Reinforce Self Management Skills
  (Red-Yellow-Green tool)
• Uptitrate meds to target dose
• ID Patients for Care Management

Q1. What are we trying to accomplish? Q2. How
will we know we have made a difference? Q3. What
changes are we willing to make? 3.12.2009
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How did we start?

• System resources and commitment
• Abbott Northwestern Hospital Allinas largest
• Built relationships
• Started with the evidence
• Started looking at failures
• Used our own experience to builda case for
  change

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Three Types of KnowledgeNeeded for Change

• Science of care
• Beta Blockers, ACE/ARB
• Science of systems
• Standard order sets Make it easy to do the right
  thing hard to do the wrong thing
• Science of implementation social change
• Evidence based leadership and management
• Leadership - TPOV, coaching, use of power
• Management -embedding changes in a social system,
  checking back (execution)

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Systems to Help Clinicians DoThe Right Thing
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Who should you get on theteam and how should you
start?

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A Model to Lead Change

• Establish the compelling why
• Develop a tangible vision
• Align leadership to the vision
• Set and focus on goals
• Communicate
• Focus on the what, how, whoP D S A Test
  ideas rapidly on a small scale
• Provide measurement and feedbackGet buy-in from
  stakeholders use data to overcome resistance
• Teach leaders to lead
• Check back

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Develop a Tangible Vision

• No one will come back to our hospitals
• within 30 days because of
• A poor handoff from the hospital to home, SNF or
  other care setting because of an unstable
  patient, or poor information flow to the
  post-hospital clinician
• An outpatient setting that was not prepared to
  care for the patient and to continue the care
  plan started in the hospital
• A patient who was not prepared to manage their
  condition when they left the hospital
• Not understanding our patient's goals, values and
  preferences for end of life care.

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Cullum, L. The New Yorker May 9, 2005
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What difficulties did we encounter?

• Questions we heard
• Why are we doing this work?
• Who decided we would focus on HF?
• What is the measure?
• What is a readmission?

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Challenges Scope

• Of 1302 screened patients, Rich study excluded
  633 out-of-area 141 going to nursing home 19
  dementia or psychiatric illness 68 terminally
  ill
• Mission of project is to include those groups

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Challenges - Followup SettingsA Plan for the
Next Clinician

• Initial attempt Insert a prompt for discharge
  recommendations for primary physician in
  templated discharge summary
• Encourage uptitration of ACE/ARB and beta
  blockers
• Last hospital weight and vitals automatically
  placed in summary

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Challenges - Followup SettingsA Plan for the
Next Clinician

• This summer, a script for the first visit was
  developed, emphasizing symptoms, weight,
  medications
• Scripted visit to be introduced in Allina Medical
  Clinic Offices first
• What work is done by whom - reliably

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Challenges Followup Settings SNF

• In nursing homes, availability of daily weights
  and 2 gram Na diet a priority
• Timely FU by SNF clinician CMS requires visit
  within 30 days
• Focus patient discharges to facilities staffed by
  Allina SNF clinicians

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Additional Challenges

• Geography and variety of post-hospital settings
  for follow up
• Difficulty in arranging early post-hospital
  visits
• Reliability of order set use
• Severity of illness and comorbidity
• Polypharmacy and medication reconciliation

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Challenges Early Post-Hospital Visits

• Appointments made by hospital staff
• Availability of 7 day coverage for that
• Some groups objected
• Many physicians were happy to work patients in
  realizing that responsibility for care best met
  by early visit
• By spring 09 still only 67 patients had 3-5 day
  appointment scheduled

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Challenges CHF Discharge Order Set Use

• Feedback on Heart Failure discharge order set use
  given to two major groups even before the project
• 88 last 3 quarters of data
• Misses related to memory, failure to realize the
  case was likely to be coded as CHF
• Guardrail project to prompt discharge order set
  use in medical record

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Challenges Discharge Navigator Provides
AlertReminder to Use an HF Discharge Order Set
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Challenges Severity and Comorbidity

• Review of readmissions
• Hospitalizations for other conditions atrial
  fibrillation, venous thrombosis, abdominal pain,
  acute coronary syndrome, urosepsis, staph sepsis
• High prevalence of end stage renal disease in
  readmission group
• Aortic stenosis treated with palliative approach

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Challenges Polypharmacy and Med Rec

• Despite attention, substantial percentage of
  patients do not understand meds at time of first
  phone call 30
• Disagreement between discharge summary and
  discharge instructions 15-46 of the time
• Attempt by physicians to get timely information
  to referring physician led to dictation before
  discharge orders

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ANW D/C Summary Meds Not Pt Instruction Meds
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Challenges Polypharmacy and Med Rec

• New medication reconciliation format in medical
  record
• Cardiology group agreed to a format of
  communication which should guarantee that summary
  matches instructions
• Patient education and length of lists remain
  major challenges

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ANW Percent of Unique HF Patients with One or
More Inpatient Readmission(s) Within 30 Days
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ANW Number of Unique HF Patients Who Had Oneor
More Readmission(s) Within 30 Days
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ANW Average Number of Readmissionsper Unique HF
Patient per Month
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ANW Percent of HF Patients WhoDied During Their
first admission or onthe readmission Within 30
Days
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HF Inpatient Mortality
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Allina HF Inpatient Mortality
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Questions?

• The End