Multifaceted Care Model for CHF Improves Health System and Patient Economic Outcome

Abstract

Introduction Inconsistent piece-meal care for a chronic multidimensional disease like CHF results in poor clinical outcomes, therefore a chronic disease Care model that provides multifaceted holistic chronic disease management in the post-acute setting, aligning a multidisciplinary dedicated heart care team to a narrow network of home/community service providers implementing evidence based protocols across the continuum; namely a Care pathway improves outcomes. Specifically, this pathway may include daily inpatient CHF identification and navigation as follows: Heart protocol implementation & training at exclusively partnered Skilled Nursing/LTAC/Home Health after concerted CHF Education (at those facilities) of Nurse practitioners (32 hours) RN Aides (3 hours) and RN (6 hours) of evidence based curriculum.Participating in daily phone huddle along with daily telehealth from the partnered facilities and home health with daily reporting/monitoring of progress eg., vitals, diet, PT/OT progress, etc.Incorporating care of chronic comorbidities including Diabetes and COPD and working concomitantly with those Care pathways.Discharge planning under the supervision of central CRNP and multi-disciplinary team including physician follow-up The above model and it's pathways revealed improvement in clinical outcomes, particularly 30 day readmissions that were reported at the HFSA 2018 but the economic impact of such interventions are unknown. Hypothesis The above mentioned comprehensive approach to HF and it's proven improved clinical outcomes may also translate into economic savings. Methods A total of 1982 Allegheny Health/Highmark (AHN) patients are on the above mentioned Care pathway, out of which 337 were identified (from May 2017 until Dec 2018) as possible matches to patients outside of the system (deemed as “Market”) with similar attributes such as clinical severity, comorbidities and index facility ie., tertiary vs. community hospitals. The above match was blinded and performed by an independent non clinical entity to maintain investigational integrity. Results After placement on the pathway, patient cost defined as per member per month (PMPM) was less expensive than market by $357 primarily driven by 30% decrease in post discharge inpatient cost and 12% decrease in post-acute costs (see Fig 1). Conclusion Economic benefit can be achieved in tandem with better clinical outcome via multifaceted CHF care.