261 - Application of a Multi-Disciplinary Approach to Reduce Heart Failure Readmissions in the Post-Acute (Home Care) Setting

Abstract

Background/Objective: American Outcomes Management's (AOM) Heart Failure (HF) program was designed to support national quality initiatives focused on reducing the rate of HF readmissions. The guidelines to lowering readmission rates called for (1) implementation of HF specific quality improvement efforts and performance monitoring, (2) medication management and (3) implementation of sound transitional practices for effective discharge and follow-up processes. The objective of this program is to validate the importance of utilizing multi-disciplinary approach for early symptom recognition of decompensating heart failure and implementing timely interventions to prevent re-admissions. Methods: Data was obtained from 77 patients treated by the pharmacy between June 2013 and September 2015. Data included 30 day re-admissions for HF and non-HF related admissions, all cause re-admissions, all-cause mortality, HF mortality, and improvements in both Karnofsky (KPS) and Minnesota Living with Heart Failure Questionnaire (MLWHFQ) 30 days from Start of Care (SOC). We utilized a comparative outcomes database correlating real time services rendered with health-related quality of life (HR-QoL) and functional status. Results: Results show 6 out of 77 patients (7.8%) with a heart failure related admissions (HFRA) and 13 out of 77 patients with an all cause related admissions (ACRA) in the two year period of the program as shown in the tables 1 and 2 below. The average Karnofsky Performance went from 65 at start of care (SOC) to 72 at 30 days (11% improvement) while the Minnesota Living with Heart failure (MLWHFQ) score went from 78 at SOC to 36 at 30 days (54% improvement). The combination of implementing sound transitional care practices, utilizing CHFNs, incorporating a MNT and HF dedicated pharmacists in HF care validates the importance of utilizing a multi-disciplinary approach for early symptom recognition of decompensating heart failure and completing critical assessments to avoid treatment failures, implement timely interventions to prevent re-admission and formulate effective teaching plans for inotrope patients in the post-acute care (home care) setting. This approach allowed AOM, prescribers, patients and caregivers to address and answer questions regarding transitional care readmission risk to yield the best clinical outcomes for patient management. Conclusions: Utilizing a multi-disciplinary approach in application of expert consensus endorsed measures plays an important role in reducing HF re-admissions and optimizing functional status and HR-QoL in patients with advanced heart failure on inotrope therapy in the post-acute (home care) setting.