Clinical Pathways Heart Failure Webinar AMGA May

Transcription

1 Clinical Pathways Heart Failure Webinar AMGA May Randall C. Starling, MD, MPH, FACC,FESC Professor Of Medicine Heart Failure and Cardiac Transplant Medicine Heart and Vascular Institute Cleveland Clinic Lerner College of Medicine, CWRU Cleveland Clinic Cleveland OH USA

2 Survey Results Survey with 13 questions sent to AMGA listserve n=50 Survey designed to determine use of clinical pathways in HF care Data represents 13 of 50 responses 26%

3 Questionnaire Does your hospital have an electronic medical records? Yes or NO Yes 100% Does your program have standardized order set for inpatient treatment of acute decompensated heart failure? Yes or No Yes 54% Does your hospital have CARE PATHS for heart failure treatment? Yes or No Yes 38%% If YES for inpatient care Yes or No Yes 23% If Yes for outpatient care Yes or No Yes 15% Does your program have a specific team to provide inpatient heart failure care? Yes or No Yes 54%

4 Questionnaire Does your program have a Heart Failure Disease Management Clinic with dedicated staffing with expertise in HF care? Yes or No Yes 69% Does your HF program have a committee that reviews data periodically on HF admissions demographics and readmission metrics. Yes or No Yes 85% Does your HF program have a standardized process for discharging HF patients from the hospital? Yes or No Yes 46% Does your HF program require follow up visits within 1 week of hospital discharge? Yes or No Yes 92%

5 Questionnaire Does your HF program require follow up visits at specific intervals after hospital discharge? Yes or No Yes 46% Does your HF program offer home visits for homebound HF patients? Yes or No Yes 85% Does your HF program work directly with Skilled Nursing Facilities to optimize care of HF patients? Yes or No Yes 85% Does your HF program offer structured HF education classes and or via written or electronic media? Yes or No 62%

6 Questionnaire Question: Please indicate the 30 day ALL CAUSE readmission rate for heart failure at your hospital Number Who Answered: % 0 0% 20-25% 1 8% 15-20% 5 38% 10-15% 6 46% less than 10% 1 8% Question: Does your program offer heart transplant and or LVAD therapy? Number Who Answered: 13 Yes No % 62 %

7 Survey Take Aways EMR common Care Paths <50% Discharge Process not standardized Discharge Follow up very common Education materials provided GAPS: common practices to optimize care and value? - Risk Stratification

8 Introduction Accurate risk assessment tools to predict readmission are needed - Predicting risk of readmission and reducing readmissions are two separate challenges Validated care paths to reduce readmissions or Episode of Care (EOC) are needed Kociol R et al. Am H Jour 2013;165:

9 Hypothesis HF Clinical Pathways will: improve quality of care Reduce variability of care Improve value and Reduce cost

10 We asked the question? Are readmissions a sign of poor quality care?

11 Are all readmissions bad readmissions? Conclusions: - Readmissions could be adversely affected by a competing risk of death. - One simple measure isn t enough? Gorodeski, Starling, Blackstone. N Engl J Med 2010: 363: Heidenreich P et al. J Am Coll Cardiol Jul 27;56(5): Krumholz H et al. JAMA. 2013;309(6):

12 Kaplan-Meier curves for freedom from A, all-cause mortality, and B, all-cause rehospitalization stratified by discharge status. SNF: skilled nursing facility N= Medicare 24.1% to SNF Adjusted HR 1.75 Adjusted HR 1.08 Allen L A et al. Circ Heart Fail 2011;4: Copyright American Heart Association OPPORTUNITY: PROCESS OF CARE FOR SNF

13 From: Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals JAMA. 2012;307(10): doi: /jama Reducing Readmissions Labor intensive EXPENSIVE OPPORTUNITY: TEAM WORK TO IMPROVE OUTCOMES Mortality Reduced Also Figure Legend: End-of-life expenditure index (EOL-EI) ranges, in Canadian dollars, are <$ (US $29 970) for the low EOL-EI category, $ to $ (US $ $34 965) for the medium EOL-EI category, and >$ (US $34 965) for the high EOL-EI category. AMI indicates acute myocardial infarction; CHF, congestive heart failure. Ong MK et al. Circ Cardiovasc Qual Outcomes 2009;2:

14 One thing is certain: Rehospitalization after heart failure admission is complex, multifactorial, and not clearly related to quality. O Connor and Fiuzat. Editorial Comment. JACC Vol. 56, No. 5, 2010.

15 WHY PATIENTS ARE READMITTED FOR HEART FAILURE Severe heart failure Polypharmacy Inadequate treatment End-of-life Shortened LOS Multiple co-morbidities Elderly, frail, confused Lack of followup Healthcare illiteracy Poverty, social issues Medical noncompliance Don t purchase meds Don t take meds Don t call when sick

16 HVI Readmission Chart Review

17 Concept diagram opportunity Unplanned, Avoidable (?) Poor care 30-day HF Readmission Rate All Cause: HF related other Planned, Appropriate Unavoidable CRT implant Appendectomy

18 Number of selected strategies implemented and risk-standardized readmission rates (RSRRs). Bradley E et al. Circ Cardiovasc Qual Outcomes 2013;6: Copyright American Heart Association

19 Discharge Checklist Pilot J72 Heart Failure Discharge Checklist PILOT Admission Date: Sticker Nursing Date / Initials? Care Partner Identified? Nursing HF Education with Booklet?Disease Education?Daily Weights (patient calendar)?activity level?i & Os?Low Sodium Diet?Fluid Restriction?Medications - Hand-outs given - Initial Introduction - Reinforcement - Teach Back? Survival Skills Class/EMMI TV Education (Course 560) Multidisciplinary Consults Date / Initials? Transitional Coach Consult? age >65 years? if needed, consult for high risk? Seen by Transitional Coach? If identified on Nursing Assessment: Nutrition consult placed? If Nutrition consult not needed: Place Nutrition Screen? Seen by Nutrition? Pharmacy Education Consult placed for patients admitted w/ primary diagnosis heart failure? EXCEPT post-cts patient? Seen by Pharmacy Physicians/Nurse Practitioners Date / Initials? Order for social support services/home care services/heart Care at Home, if indicated? Near optimal pharmacologic therapy initiated or achieved and any intolerances documented? No symptomatic supine or standing hypotension (Orthostatic BPs require order)? " Dry Weight" established and patient/caregiver informed of this goal? Near optimal volume status achieved? Stable renal function and acceptable electrolyte panel? Core Measure Status Completed: Yellow Triangles Cleared? Discharge medication reconciliation completed MD/NP: PLEASE LIST PROVIDER PATIENT IS TO FOLLOW UP WITH (below and on blue appt. shee Identify Primary Care Physician - Name 7 Day LIP Appt/30 Day Cardiology MD Appt **BLUE APPT. SHEET COMPLETED** 7 Day LIP Appt/30 Day Cardiology MD Appt SCHEDULED (per HUC) Case Management Date / Initials? Discharge Needs identified? Home Care visit offered? Final post-discharge arrangements made

20 Explanation Comprehensive Domains: Nursing, Case Management, Pharmacy, and Physician/Mid-Level Provider Addresses Continuum of Care: Inpatient Care, Transition, and Followup Care Circ Heart Fail Nov;5(6):680-7.

21 HF 30 Day Readmissions All Cause 30 Day Readmissions January 2014 to February 2016

22 Heart Failure 30 Day Readmission Rates Patients on HF Electronic Checklist 30% Quarterly Performance Goal 20% 25% 20% 15% 10% Q Q Q Q Q Q Q Q * Source: EBI Tableau * Through February 2016

23 HF YTD 30 Day Readmission Rates Source: Outcomes Review *The most recent quarter may not contain the full three months

24 Heart Failure 30 Day Readmission Rates Patients on HF Electronic Checklist Monthly Performance Goal 20% % 18.2% JAN.'16 FEB.'16 Source: EBI Tableau 2016.

25 All Cause 30 Day Readmission Rate Heart & Vascular Institute Source: Outcomes Review

26 Office of Clinical Transformation Develop Care Paths to standardize care, reduce variability, improve value System wide order sets System wide education tools Dedicated in patient HF team Dedicated out patient HF team Dedicated HF NPs both inpt and outpt and transitional care

27 References Care Processes 1: Fonarow GC, Albert NM. Preface. Team-based Care for Heart Failure. Heart Fail Clin Jul;11(3):xixii. 2: Albert NM, Barnason S, Deswal A, Hernandez A, Kociol R, Lee E, Paul S, Ryan CJ, White-Williams C; American Heart Association Complex Cardiovascular Patient and Family Care Committee of the Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Transitions of care in heart failure: a scientific statement from the American Heart Association. Circ Heart Fail Mar;8(2): : Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Inge PJ, Mehra MR, O'Connor CM, Reynolds D, Walsh MN, Yancy CW. Improving evidence-based care for heart failure in outpatient cardiology practices: primary results of the Registry to Improve the Use of Evidence- Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF). Circulation Aug 10;122(6): : Albert NM, Fonarow GC, Yancy CW, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride M, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Outpatient cardiology practices with advanced practice nurses and physician assistants provide similar delivery of recommended therapies (findings from IMPROVE HF). Am J Cardiol Jun 15;105(12): : Walsh MN, Yancy CW, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Fonarow GC. Electronic health records and quality of care for heart failure. Am Heart J Apr;159(4): e1. 6: Albert NM, Fonarow GC, Yancy CW, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride M, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Influence of dedicated heart failure clinics on delivery of recommended therapies in outpatient cardiology practices: findings from the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF). Am Heart J Feb;159(2):