Managing heart failure risk factors: Successful strategies
David Majure, MD, medical director, mechanical circulatory support program, Sandra Atlas Bass Heart Hospital at North Shore University Hospital in Manhasset, New York, says reducing readmissions is about a strong system approach and doing good heart failure care.
At his hospital, a group known as Health Solutions targets patients subject to the Heart Failure HRRP umbrella and efforts are made to connect with them at home.
The way it works, he explains, involves calling the patients at home and ensuring they have adequate resources at home and following up appropriately. By doing this, it helps reduce readmissions and the hospital’s decreasing numbers have shown it’s a success.
“If they become readmitted, they help them identify factors to help minimize their readmission,” Majure says.
The American Heart Association’s Get With The Guidelines—Heart Failure program is a hospital-based quality improvement program that provides assistance for providers to maintain current practice guidelines.
The guidelines noted that scheduling an early follow-up visit (within seven to 14 days) and early telephone follow-up (within three days) of hospital discharge are reasonable. In response to this recommendation, most HF programs include a discharge follow-up phone call though data in response to this recommendation is mixed. Therefore, Vuckovic notes each program needs to evaluate what works for their population.
“Studies which have included follow-up phone calls usually include other interventions,” she says. “There is a handout for TARGET-HF which guides the process and scripts the call.”
For example, a clinician-initiated discharge phone call is a simple and cost-effective method that allows clinicians to connect to the patients after their hospital discharge to check on their well-being, review or reinforce discharge instructions, and address issues that may potentially lead to adverse outcomes.
“Dealing with heart failure patient’s basic needs is essential in helping them manage their disease,” Vuckovic says. “For example, one inner-city teaching hospital recognized that providing housing for those who are homeless during the transition phase led to patients being more likely to attend follow-up appointments.”
Hebrew Home utilizes the AMDA’s (The Society for Post-Acute and Long-Term Care Medicine) Heart Failure Clinical Practice Guide as its protocol for treating CHF patients. Palace explains the guidelines are in a small handbook, easy to read, and provide clinicians with key points to identify heart failure, assess it, and treat and monitor achievements. This keeps everyone on the same page with best practices and ensuring they are practicing the most current medicine.
“We also have full-time physicians on staff and provide comprehensive training to all of our clinical teams on what to look for and what steps to take,” he says. “Through these efforts, we are able to manage the majority of patients in our facility and thus have a low number of readmissions.”
Related article: How Health Systems Use Pharmacists to Reduce Readmissions
Anecdotally, he shares families often talk about how their mom or dad when at different facilities, would end up in ER every few weeks with heart failure, but since coming to Hebrew House, they haven’t gone out at all. It’s a credit, Palace says, to managing these patients in-house.
Hebrew Home has also invested in technology, such as contact-free continuous vital sign monitoring, to help it identify patients at risk for CHF exacerbation. This is a trend that others are following and Palace says it’s important because it acts as the eyes and ears when the nurse is not in the room, which is a large part of the time.
“In CHF patients, a key risk to look for is an increase in fluids. Fluid builds up and when patients lie down, this fluid moves from their legs and collects in their lungs. An indicator we look for is shortness of breath,” Palace says. “We also monitor weight, a quick increase in weight is another way to monitor for fluid retention. We are also seeing a lot of new technology coming to the market specifically designed to help identify changes.”
The facility has also embraced the ReDS Vest, a recently-approved technology. The technology is a vest a nurse applies a patient which has a built-in sensor that reads across the chest from front to back and can quantify total lung water volume. That is also significant in helping to identify heart failure patients.
Hospitals successful at reducing readmissions that were enrolled in the American College of Cardiology’s Hospital to Home initiative, a resource for hospitals and cardiovascular care providers committed to improving transitions from hospital to home and reduce their risk of federal penalties associated with high readmission rates, created a summary of 10 key practices. Of the 10 practices, three centered on medication management.
“Education about the purposes of each medication, changes in doses/frequency, which to stop, which are new, and how to take them correctly were identified as essential to self-management. Medication reconciliation is essential,” Vuckovic says.
Palace says medication compliance is much easier to manage in a skilled nursing facility where physicians are keeping a close eye, and the clinical staff is helping to ensure adherence.
Vuckovic says that culturally appropriate multidisciplinary discharge planning and education has been shown to facilitate compliance and decrease readmissions. Research has shown that self-care (e.g., diet, medication, and symptom management) is largely insufficient in ethnic minority populations, indicating an area where more emphasis is needed—especially as self-care can be a major component of reducing readmissions.
“We need to shift our approach from hospital care to providing self-care at home since the majority of the patients’ care takes place in the home, not the hospital,” she says. “Providers should seize every opportunity to reinforce self-care principles and education.”
Nicholas Hamm is an editor with Managed Healthcare Executive. Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.