How to keep heart failure patients out of the hospital

Nationwide, death and re-hospitalization rates remain high among people with heart failure who have transitioned from in-patient to out-patient care. As a result, OSF HealthCare has made it a priority to reduce its own mortality and readmission rates among this population using innovative methods and collaborative thinking.

“We developed a Ministry-wide, multidisciplinary council to track this work and figure out where we should focus,” said Marlene Hunteman, Director of the Cardiovascular Service Line for OSF HealthCare. “We decided early on that any solutions developed had to impact all levels and entities of care. But first, we needed to start with in-patient care.”

Research among our cardiovascular teams found a variety of ways the health care system could help prevent patients from returning to the hospital or worsening of their condition. This includes early follow-up with patients after they are discharged from in-patient care and making sure individuals have an appointment set up before they leave the hospital. Other solutions include making sure patients have the appropriate medications to treat their heart failure and ensuring they have access to supportive care services.

The next step was to come up with ideas to make these solutions a reality. A core team, made up of clinicians, administration and leaders, meets weekly to brainstorm concepts and keep the project moving. The group chose to first tackle how people are transitioned out of the hospital.

Changing standards of care

Evidence shows that every time someone with heart failure returns to the hospital for treatment, their mortality rate increases by 30% due to their condition getting worse. But peer-reviewed literature also shows if patients receive a follow-up appointment with their provider within five days of being discharged from in-patient care, their chance of readmission is greatly reduced. That’s because clinicians can determine whether medications need to be adjusted and assess patients for deterioration.

To ensure patients receive the follow-up care they need, the council developed two standards of care that all clinicians within the health care system should follow.

  • When patients with heart failure leave the hospital, they will receive a phone call or home health visit within two calendar days to make sure they are doing OK and to remind them of their upcoming follow-up appointment.
  • Patients are expected to visit with a provider within five days of hospital discharge.

“Before, we left it up to our patients to schedule follow-up appointments,” said Barry Clemson, Heart Failure Medical Director of the Cardiovascular Service Line for OSF HealthCare. “This usually wasn’t done in the time span where it could’ve made a difference to their health.”

Working with the Performance Improvement’s Solution Design and Integration team, a part of OSF Innovation, a plan was devised to give the scheduling responsibility to a patient’s case manager who is already a part of the patient’s care team and can collaborate with him or her to find an open slot on a provider’s schedule. This is instead of leaving the role to an outside scheduler who doesn’t know the patient in question. This process has been in place since December 2017 and was recently expanded Ministry-wide in June 2018.

“Re-hospitalization rates for patients who do not complete that follow-up visit are 23% while rates for those who do complete their visit is 16%,” said Hunteman. “Across the nation, the best hospitals that we see run at about a 16% readmission rate.”

The council set a goal of 90% completion for hospital facilities to make sure patients have a five-day follow-up appointment before being discharged, they receive their assessment and reminder call within two calendar days, they show up to their appointments and that their office visit is completed. Some OSF HealthCare sites are above that 90% threshold every week.

Heart failure project far from over

While many OSF HealthCare hospitals are doing what they can to ensure heart failure patients don’t have to return to the hospital for treatment, individuals with the disease can’t always attend their follow-up appointments. The next step is to set up a project to determine what barriers patients face in keeping themselves healthy.

The Heart Failure Council is also working toward developing long-term solutions to make sure patients have the appropriate medications to treat their heart failure and ensuring they have access to supportive care services. Stay tuned to the OSF HealthCare blog as more of these projects are rolled out.

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