CONNECTING CARE TO HOME FOR HEART FAILURE PATIENTS: AN EFFECTIVE STRATEGY TO REDUCE HOSPITAL READMISSION RATES

Abstract

Hospital readmission for heart failure (HF) is a significant issue. Connecting Care to Home (CC2H) is a partnership program between the hospital and community agencies, aiming to improve transitional care for HF patients. The goal of CC2H is to improve patient outcomes and reduce system costs. HF patients from the medicine and cardiology wards at London Health Sciences Centre (LHSC) with moderate care needs were assessed for CC2H enrollment. Once discharged home, patients received enhanced support from an interprofessional HF care team, including ongoing in-home monitoring/intervention, with access to the CC2H team via a 24/7 phone line and timely HF clinic follow-up. Importantly, there was consistent delivery of HF education and self-management support in both the hospital and home setting. As of December 31, 2018; 132 patients had completed the CC2H HF pathway. A comparative population of 240 HF patients at LHSC showed a 30-day readmission rate of 27%, while for the CC2H HF patients it was 15%; a 43.2% reduction. The CC2H HF strategy reduced the 60-day readmission rate by 36.8%. At 30 days, the total cost of care for the comparative HF patient was $15, 660 and for the CC2H HF patient was $13, 554; a cost savings of 13.5%. At 60 days, the total cost savings per CC2H HF patient was 14.0%. The comparative HF patient group had an average length of stay (LOS) of 8.9 days, while the CC2H HF group was 8.5 days; a reduction of 3.9%. This is slightly higher than the average estimated length of stay (ELOS) of 8.1 days; however 61.4% of CC2H HF cases had a lower LOS than ELOS. In 2017, CC2H patient experience feedback surveys were sent to 58 HF patients, with approximately 55% responding. Information was collected on the patient’s index hospitalization; their transition back to their home and community after hospitalization; and the care received in their home and community during the time on CC2H. Overall, the feedback was positive with 14 out of 28 questions being measured quantitatively via a Likert scale approach. The other questions revealed anecdotal examples of opportunities for improvement. The CC2H HF intervention significantly reduced the 30 and 60-day readmission rate, which provided the greatest cost avoidance. This transitional care model provides greater continuity of care for HF patients in the early period following hospital discharge. These findings support the expansion of the CC2H model of care.