Reengineering the Discharge Management of Heart Failure Patients Discharged to Skilled Nursing Facilities Utilizing a Multidisciplinary Team Approach Reduces 30-day Readmission Rate

Abstract

Introduction Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge is the large volume of hospitalized Heart Failure (HF) patients (4,000/year) with a historically high 30-day readmission rate (27%). HF patients discharged to Skilled Nursing Facilities (SNF) (23%) were at higher risk of readmission, p-value Hypothesis Development of a designated multidisciplinary HF Team (NP, PharmD, Case manager and SNF leadership) approach that integrates a standardized comprehensive pre/post discharge multidisciplinary management plan will decrease 30-Day readmission rates. Methods January 15 - April 1, 2019 was the implementation phase of the SNF Heart Failure Readmission Reduction Initiative (SNF -HFRRI) Pilot Project which included generation of a daily patient list with Primary HF (ICD-10) and HF anticipated discharge list from case management. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients identified to be discharged to a SNF were flagged for further in-depth pre-discharge HF NP consult/PharmD counsel and to develop a warm handoff to SNF leadership. Post discharge HF weekly telephone assessment with SNF senior RN leadership and attendings were conducted. Retrospective review of prospectively collected data was analyzed based on age, gender, NYHA, ACC stage, LOS, Unit of discharge and 30-Day Readmission and included Pre-SNF-HFRRI (June 1, 2018 - January 15, 2019); Implementation Phase (January 15, 2019 -March 31, 2019); Post SNF-HFRRI (April 1, 2019 November 15, 2019). Results We identified 182 HF patients (88-Pre-SNF-HFRRI and 94 Post SNF-HFRRI). Continuous variables (age, LOS) and categorical variables (gender, NYHA, LVEF, ACC stage, reason for readmission, hospital unit discharged and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank, chi square and Fisher's exact test. The groups were comparable to age, LOS, LVEF, ACC class, units discharged. A structured weekly post discharge phone assessment incorporating Guideline-Directed Medical Therapy was statistically significant, p Conclusion Our newly integrated multidisciplinary HF team approach that incorporates a structured post-discharge collaborative approach can prevent avoidable 30-day readmissions and improve discharge preparedness.