In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: 2 Years’ Experience in the Heart Failure Bundle Payment Care Improvement Initiative

Abstract

Background Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) are vulnerable to poor outcomes. CMS developed the Bundled Payments for Care Improvement Initiative (BPCI) which provides participating providers shared savings based on costs for 90-day episodes of care with the purpose of improving quality and cost-effectiveness. Greater availability of clinical staff has shown promise in improving outcomes for SNF patients. The effect of cardiology consultation for SNF patients with HF has not been evaluated. This study evaluates the impact of a SNF-based cardiologist-led HF program on 90-day readmission rate and resource utilization. Methods We performed a retrospective analysis using Medicare claims data of BPCI-enrolled HF patients admitted to St. Joseph's Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program. Data were collected from October 2015 to September 2017. Readmission rates and cost savings versus CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs, 24 of which had no HF program, 7 of which had standard programs composed of a multidisciplinary team of dietary, rehabilitation, social work and clinical staff. The SJC program additionally instructed staff to request cardiac consultation for patients with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitative therapy. Cardiology rounds were conducted weekly and management was provided in the context of achieving subacute rehabilitation goals, clinical stability, and preparing for community discharge. The cardiologist identified and alerted staff to patients deemed high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results There were 602 total HF episodes in the 24-month evaluation period. Seventeen patients were admitted to SJC; 218 patients to a facility with a HF program; and 367 patients to a facility without a HF program. The case mix complexity at SJC included a higher percentage of patients with major complications and comorbid conditions (71% vs 60% for all other SNFs and 64% for SNFs with HF programs). More than 50% of patients at SJC prompted specialty consultation. Compared to other facilities, the percentage of SJC patients readmitted in the 90-day post HF hospitalization period was significantly lower (23.5% vs 43.4% (p = .052) for all other SNFs; and 48.2% (p = .025) for SNFs with a non-cardiologist based HF program). SJC achieved a higher margin of cost savings compared to facilities that did not have a consulting cardiologist (39% vs 15%). Conclusion Patient-centered cardiology consultation for high risk HF patients may effectively reduce re-hospitalizations and resource utilization within SNFs. These results identify a potential gap in care for this vulnerable cohort of HF patients and suggest that incorporating a cardiologist into the management team may impact outcomes.