In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: Lessons Learned upon Completion of 3 Years in the Heart Failure Bundle Payment Care Improvement Initiative

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Background Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) have poor clinical outcomes despite immense resource utilization. CMS developed the Bundled Payments for Care Improvement (BPCI) program, providing shared savings to participating providers for 90-day episodes of care with the purpose of improving quality and lowering costs. SNF-based cardiology consultation for HF patients was shown in a pilot study to reduce costs and 90-day readmission rates over an initial 2-year enrollment period. This study evaluates the comparative impact of that SNF-based cardiologist-led HF program on readmission rates and costs after completion of 3 years in the BPCI Model 3 program. 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 (HFP). Data were collected from October 2015 to September 2018. Readmission rates and cost savings vs CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs: 24 of which had no HFP; 7 of which had a HFP employing dietary, rehabilitation, social work and medical staff, with limited to no direct cardiology consultation. Cardiology consultation was requested for HF patients at SJC with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitation. Weekly cardiology rounds provided HF management within the context of achieving clinical stability, rehabilitation goals and preparing for community discharge. The cardiologist identified patients at high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results There were 835 total HF episodes in the 3-year evaluation period: 22 were admitted to SJC; 291 were admitted to facilities with a HFP; and 522 to facilities without a HFP. The case mix at SJC included more patients with major complications and co-morbid conditions (77% vs 65% for all other SNFs, and 60% for SNFs with a HFP). Compared to other facilities, hospital readmission from SJC was significantly lower in the first 30 days after HF hospitalization (4.5% vs 23.6% (p = .018) for all other SNFs; and 23.7% (p = .019) for SNFs with a HFP), and remained lower for the 90-day episode duration (27.3% vs 44.8% (p = .052) for all other SNFs; and 48.8% (p = .026) for SNFs with a HFP). SJC achieved a higher margin of cost savings compared to facilities without a consulting cardiologist (28% vs 11%). Conclusions Incorporating a cardiologist into SNF HF teams consistently reduced re-hospitalizations and costs for HF episodes over a 3-year period. Further evaluation is needed to understand why outcomes among SNFs with standard HF programs were worse despite a lower case mix complexity. Weekly assessments and clinical management incorporating patient-centered rehabilitation goals may improve outcomes for this vulnerable HF population.