Abstract 260: COMPASS-CP for HF: An Electronic Application to Capture Patient-Reported Outcomes of Individuals with Heart Failure

Abstract

Purpose: Heart failure (HF) admission variance is significantly influenced by functional, social, and behavioral health determinants. The Institute of Medicine and Centers for Medicare/Medicaid Services now recommend that these determinants be captured in the electronic health record (EHR) for personalized, value-based care and population health management. However, mechanisms for doing so within clinical workflow have not been fully developed. The purpose of this pilot project was to capture and evaluate patient-reported outcomes (PROs) prior to hospital discharge using a HF-specific version of Comprehensive Acute Care Services-Care Plan (COMPASS-CP) (Duncan et al, Circ Cardiovasc Qual Outcomes 2018), a web-based application that integrates PROs into clinical care to generate personalized electronic care plans. Methods: Consecutively sampled patients with HF admitted to Wake Forest Baptist Medical Center Cardiology Service were assessed by a Cardiac Wellness Educator or Research Coordinator (RC) using the COMPASS-CP for HF application. The RC performed 30-day post-discharge phone calls to collect PROs and healthcare utilization. Results: Seventy-six patients (mean 65yrs, 35% female, 31% black, 95% living at home) provided COMPASS-CP PROs. The COMPASS-CP PROs revealed 47% with fair/poor health ratings and deficits in physical function included 63% unable to walk 6 min without difficulty, 59% unable to negotiate 10 steps independently, and 24% with at least one fall within 3 months of hospital admission. Deficits in health management included 25% unable to purchase meds, 27% forgot to take meds often or sometimes, 30% without a caregiver, and 64% lacked a living will. Only 51% properly identified at least one HF risk factor and only 26% knew HF symptoms that warrant contacting their provider. Strikingly, deficits in psycho-cognitive function indicated 41% screened depression positive yet only 21% had depression listed in the EHR and 53% failed 5 minute 3-word recall. Forty-seven patients (62% of original sample, mean 62yrs, 23% female, 43% black, 93% living at home) provided 30-day PROs. The 30-day PROs revealed low Global PROMIS-10 scores (mean 30.6 on 10-50 scale), 60% with fair/poor physical health ratings, 66% with moderate to severe difficulty in everyday ADLs, 77% with moderate to severe fatigue, and 30% with ED visits and/or readmissions. Conclusion: COMPASS-CP for HF detected global deficits known to drive all-cause healthcare utilization. This tool can aid in the generation of personalized care plans, based on PROs and availability of community services, to improve health outcomes among individuals with HF.