Multifaceted Interventions Reduce Heart Failure Readmissions and Cost

Abstract

Introduction Preventing 30 day readmissions after index Heart Failure (HF) admission can improve morbidity and mortality, and the financial wellbeing of health care systems. One of factors affecting readmissions is inconsistent episodic care for a chronic multidimensional disease. Hypothesis A chronic disease care model that provides management to HF patients in the post-acute setting aligning a multidisciplinary dedicated heart care team to a network of home and community service providers implementing evidence based protocols may reduce 30 day readmissions and cost. Methods Allegheny Health Network, PA created a heart care model comprised of HF dedicated core physician led team incorporating business/IT and community partners to formulate a comprehensive multifaceted centralized program to transform the delivery of care to HF patients at various touch points and translate it to savings. The components include: In Patient: • Daily HF patient identification, enrollment and initiation of patient navigation to a Care pathway ie., a CRNP led HF team that continues to oversee and follow the patient during continuum of care • Trigger advanced HF team consultation for HF readmissions Post Acute: • Heart protocol implementation & training • HF evidenced based curriculum training education of NP's (32 hours) Nursing Aides (3 hours) and RN's (6 hours). • Skilled Nursing/Long term care facility/Home Health management • Partnering exclusively with nine SNF's, one LTAC and a Home Care Agency after scrutinized criteria review. • CRNP led HF team baseline assessment and medication reconciliation and completion of medical order for specific medical treatments (during emergency). • Participating in daily fifteen minute phone huddle along with daily telehealth from the partnered facilities with daily reporting/monitoring of progress with daily assessment of vitals, weights, symptoms, edema, lung sounds, ambulation, diet and PT/OT. • Discharge planning under the supervision of central CRNP • Physician follow-up • Medication reconciliation/call Pharmacy • Referral to Cardiac Rehab Out Patient/Home: • Post-acute care alignment with appointments and service (rehab, home health, etc) scheduling • Navigator RN calls to review diet/medication compliance and symptoms. Results The data reveals that there was a trend toward reduction in 30 day readmission rate (see table 1 ). Sampling of data revealed reduction in cost per month per member of approximately $309 compared to similar cohorts. Conclusion Multifaceted multidisciplinary interventions may provide reduction in readmissions at lower cost.