MaineHealth Healing Hearts Program: Improving Heart Failure Care

1
MaineHealthHealing Hearts ProgramImproving
Heart Failure Care

• Program Evaluation
• February 2003

2
Cardiovascular Health Workgroup
Chair Scott Mills, MD - Mid Coast
Hospital Representatives from

• St. Andrews Hospital
• Miles Memorial
• MaineGeneral
• Stephens Memorial
• St. Marys

• Maine Medical Center
• Southern Maine
• MidCoast Hospital
• Community Health Svcs

3
Why Heart Failure?

• Leading cause of hospital admissions
• 3000 HF admissions/yr in Maine
• 1000 at MEHlth hospitals
• Major contributor to healthcare costs
• 22 billion/yr in HF costs in U.S.
• 24 million/yr spent on HF admits in Maine
• Solid evidence base exists for effective
  treatment
• Important gaps in care identified at baseline

4
Where Did We Start?

• Baseline data Known gaps in care
• ACEI use, LVEF measured, d/c instructions
• Good models for improvement in place
• Care management SMMC, MMC
• Physician prompts SMMC
• Clinician commitment, leadership
• Excellent opportunity for system-wide care
  improvement initiative!!

5
Program Components

• Patient Education Self-management support
• Nurse Care Support/Coordination
• Provider Education and Tools

6
(No Transcript)
7
(No Transcript)
8
Healing Hearts Year 1 Interventions

• HF educational presentations to providers (all
  hosps)
• Implemented standardized HF instructions for
  inpatients (all hosps)
• HF Care Managers (7/8 hosps)
• HF Discharge instruction brochure (8/8 hosps)
• HF Inpatient Worksheet (7/8 hosps)

9
HF Program Outcomes Evaluation

• Baseline and 1-yr follow-up data from hospitals
• MaineGeneral Medical Center
• Maine Medical Center
• Mid Coast Hospital
• Miles Memorial Hospital
• St. Andrews Hospital
• St. Marys Hospital
• Southern Maine Medical Center
• Stephens Memorial Hospital

10
Data Sources

• Inpatient Data
• HF admissions (DRG 127)
• Hospital collected data
• JCAHO HF core measures
• LOS and 31-day readmission data
• Collected baseline 1-year follow-up data on
  recent HF admissions
• Baseline Sept 01 (n314)
• Follow up Oct 02 (n284)

11
Data Sources

• Patient Knowledge Behavior Survey
• Validated instrument
• Patients with HF admission who did not receive
  case management
• Mailed survey

12
Left Ventricular Ejection Fraction Measured
20 Improvement
88
68
Indicates Plt0.05 for before-after comparison
13
Left Ventricular Ejection Fraction Measured
All Hosps Mean Range
Baseline 68 8-90
Follow-up 88 13-100

Improvement in care across patient population (Change in mean LVEF measured for all patients) Improvement in care across patient population (Change in mean LVEF measured for all patients) 20
Improvement in care across MH system (Mean of the changes observed at each MH hospital) Improvement in care across MH system (Mean of the changes observed at each MH hospital) 15
Indicates Plt0.05 for before-after comparison
14
(No Transcript)
15
ACE-Inhibitor Use
25 Improvement
81
56
Indicates Plt0.05 for before-after comparison
16
ACE-Inhibitor Use

• Heart failure patients (with LVSD) prescribed
  ACEI at hospital discharge in pts without
  contrainds

All Hosps Mean Range
Baseline 56 39-73
Follow-up 81 50-100

Improvement in care across patient population (Change in mean LVEF measured for all patients) Improvement in care across patient population (Change in mean LVEF measured for all patients) 25
Improvement in care across MH system (Mean of the changes observed at each MH hospital) Improvement in care across MH system (Mean of the changes observed at each MH hospital) 26
Indicates Plt0.05 for before-after comparison
17
(No Transcript)
18
Discharge Instructions Pts Weigh Self Daily
15 Improvement
44
29
Indicates Plt0.05 for before-after comparison
19
Discharge Education
Discharge instructions specify that patient
should weigh themselves daily
All Hosps Mean Range
Baseline 29 7-83
Follow-up 44 10-72

Improvement in care across patient population (Change in mean LVEF measured for all patients) Improvement in care across patient population (Change in mean LVEF measured for all patients) 15
Improvement in care across MH system (Mean of the changes observed at each MH hospital) Improvement in care across MH system (Mean of the changes observed at each MH hospital) 19
Indicates Plt0.05 for before-after comparison
20
(No Transcript)
21
Discharge instructions Patients told when to
call if worse
37 Improvement
77
40
Indicates Plt0.05 for before-after comparison
22
Discharge Education
Discharge instructions specify when patients
should call if worse
All Hosps Mean Range
Baseline 40 10-88
Follow-up 77 58-89

Improvement in care across patient population (Change in mean LVEF measured for all patients) Improvement in care across patient population (Change in mean LVEF measured for all patients) 37
Improvement in care across MH system (Mean of the changes observed at each MH hospital) Improvement in care across MH system (Mean of the changes observed at each MH hospital) 27
Indicates Plt0.05 for before-after comparison
23
(No Transcript)
24
Other JCAHO Core Measures

• Discharge Instructions
• Activity level
• Diet
• Follow up appt
• D/c meds
• Smoking cessation advice

25
Adult Smoking Cessation Advice/Counseling
(Initial evaluation 10/02)
51 of HF patients who smoke recd smoking
cessation advice or counseling (reporting for
all hospitals except hosps 2, 5)
26
Heart Failure LOS

• All Hosps, Mean
• Year One (9/00-8/01) 4.7 days
• Year Two (9/01-8/02) 4.6 days

Mean LOS all Maine hospitals 4.3 days (Health
Web of Maine 1999 data)
27
HF 31-day Readmission Rates
4.1 Decrease
17.5
13.4
28
HF 31-day Readmission Rates(All Payers)
Mean Across Hospitals Range
Year 1 Readmit Rate 17.5 0-31
Year 2 Readmit Rate 13.4 0-18
Overall Improvement (decline in readmits) - 4.1
Indicates Plt0.05 for before-after comparison
29
(No Transcript)
30
Heart Failure Costs
31-day readmits
Provider visits
Meds, diagnostics
All inpatient admits
31
Overall Healthcare System Savings

• Within first year of Healing Hearts program,
  MaineHealth hospitals saw decline in readmission
  rates from mean 17.5 to 13.4
• MH system avoided 34 (31-day) HF readmissions
  during Q1/2 2002
• Across system, payers saved over 240,000 during
  6 mos period from avoided 31-day readmissions
  alone

Using average cost of HF admission at MH hosps
7067 Health Web of Maine 1999 data, all HF
admissions
32
Avoided CostsDecrease Hospital Losses Assocd
with HF Readmissions

• At MMC, hospital sees mean net loss per HF
  admission (2391)
• Decreased readmissions at MMC resulted in over
  43,000 in avoided losses to MMC in first 6 mos
  2002

Mean loss Mean (costs reimbursement) per HF
admit
33
Patient Behavior-Knowledge Survey

• Survey conducted June-August 2002 to gather
  baseline data about patients knowledge and
  subsequent behavior regarding heart failure.
• Baseline cohort had not received any case
  management services (nor HH educational
  information) - follow up survey will assess those
  getting nurse care management

34
(No Transcript)
35
(No Transcript)
36
Weigh Everyday Free Scales Program

• Program created in January 2002 to provide scales
  to patients who cannot afford them
• From Feb 02 through Dec 02, program distributed
  65 scales to patients

37
(No Transcript)
38
Healing Hearts Outcomes Summary

• 1. System-wide improvements are achievable!
• One of first MaineHealth-wide efforts to improve
  clinical care
• Included all MH hospitals / medical comms
• System-wide improvements apparent at 1 yr
• Population-wide improvements
• Improvements at each hospital

39
Healing Hearts Outcomes Summary

• 2. Clinical care was improved!
• Significant improvements in several key clinical
  measures of heart failure
• LVEF Measured
• ACEI use
• Appropriate discharge instructions
• Improved patient care, clinical outcomes,
  patient satisfaction!!

40
The idea is to coordinate self-management,
professional care, and community resources to
ensure continuous and appropriate care.

• The Healing Hearts program saved my life, says
  Jim Rock of Saco. I couldnt have gotten
  through that two years without them.

41
Healing Hearts Outcomes Summary

• 3. Utilization of hospital resources was
  improved, and resulted in decreased costs!
• Slight decrease in LOS
  (more difficult to assess LOS
  change)
• Improvements in 31-d readmit rates
• Associated decreases in admission costs,
  diminished hospital financial losses assocd with
  HF admissions

42
Key Contributors to Success

• System-wide approach
• Clinical leadership
• Physicians
• Nurse care managers
• Systems supporting consistent delivery of
  evidence-based care (e.g. inpatient worksheet)

43
Key Contributors to Success

• HF Nurse Care Managers!
• Made possible by support from hospitals for CM
  resources
• Participation in a coordinated approach to HF
  through the state-wide MECares Program.

44
Challenges

• Opportunities for continued clinical improvement
  in several areas
• ACEI use, smoking cessation, d/c instrs
• Continued variation in performance across MH
  system
• Challenges with sustaining adequate funding for
  nurse care management resources

45
Challenges

• Opportunities to decrease LOS
• Need to streamline data collection and feedback
• Lack of real time data feedback to clinicians
  about performance
• Burden of retrospective chart review
• Need to sustain clinician interest / use of tools
• Inpatient worksheet education materials

46
CVH Workgroup Recommendations

• Continue HF program funding _at_ MH level in order
  to continue / expand current program efforts
• Continue commitment of resources at hospital
  level for HF care management

47
Next Steps/Recommendations

• Explore opportunities for decreasing LOS
• Promote use of inpatient HF worksheet -
  providesreal-time care prompts
• - potential to streamline data collection
  and feedback
• Expand focus to include efforts to improve
  outpatient care
• Consider expanding scope of work to include
  coronary artery disease /AMI

48
Working Together
Healing Hearts CHS MaineGeneral Mid Coast
Miles MMC St. Andrews St. Marys Stephens
SMMC

• By working together as a health system, we have a
  tremendous opportunity to improve patient care!