Good Heart Failure Care Follows Patients Home

Congestive heart failure (CHF) affects nearly five million Americans. Characterized by an inability of the heart to pump enough blood to the rest of the body, CHF can be debilitating and can exact a significant toll on patients’ quality of life. The financial burden on the health care system is considerable as well: almost $30 billion is spent annually on CHF care.
That’s the bad news. The good news is that many health care providers are successfully employing a specific set of interventions to improve CHF care for patients in the hospital and after discharge, resulting in fewer hospitalizations and readmissions. There’s a growing body of evidence to draw from, which is why delivering reliable care for patients with CHF was a part of IHI’s 5 Million Lives Campaign.
“This is challenging work,” says IHI Director Diane Jacobsen, MPH, CPHQ. “Improving care for patients with CHF requires hospitals to stay focused on lots of different pieces of the puzzle simultaneously. They have to pay attention to systems issues, like how to identify the population of hospitalized patients with CHF — which is harder than it might seem — as well as clinical issues, like getting patients the right medications at the right time. Effective patient education is also key to ensure that patients know how to take care of themselves after they’ve been discharged and what resources are available to them outside the hospital. It takes a lot of coordination and leadership.”
The 5 Million Lives Campaign How-to Guide: Improved Care for Patients with Congestive Heart Failure highlights seven key care components that are also supported by The Joint Commission and the American College of Cardiologists:  
  • Left ventricular systolic (LVS) heart function assessment
  • ACE inhibitor or ARB at discharge for CHF patients with systolic dysfunction
  • Anticoagulant at discharge for CHF patients with chronic/recurrent atrial fibrillation
  • Influenza immunization (seasonal)
  • Pneumococcal immunization
  • Smoking cessation counseling
  • Discharge instructions that address all of the following: activity level, diet, discharge medications, follow-up appointments, weight monitoring, and what to do if symptoms worsen
Evidence-based CHF care may also include beta-blocker therapy at discharge for stabilized patients with left ventricular systolic dysfunction, without contraindications.
While most hospitals perform many of these steps, few perform all of them reliably; doing so, says IHI, carries the most promise for producing better outcomes for patients.
Getting the Right Care to the Right Patient
“To get it right, you have to hit all the components,” says Jan Fitzgerald, RN, MS, CPHQ, Director of Quality and Medical Management at Baystate Medical Center in Springfield, Massachusetts. This is challenging enough, but Fitzgerald says there is a more fundamental challenge that must be met first. “We know that 20 percent of heart failure patients aren’t identified as heart failure patients until discharge.” One explanation is that unrelated acute symptoms such as pneumonia or shortness of breath may be the main issues noted upon admission.
“These patients wouldn’t necessarily be flagged as patients with CHF,” says IHI’s Jacobsen. “Hospitals often code for the primary diagnosis, and a background of heart failure may not float to the top.”
Some hospitals, says IHI Director Cory Sevin, RN, MSN, are developing systems to help them do a better job at identifying all patients with CHF. “The pharmacy might flag certain medications to trigger a review of the record for an indication of heart failure,” she says, “or certain diagnoses might prompt the same ‘second look.’”
Baystate Medical Center has focused on creating some processes that specifically target CHF patients, as well as making sure that efforts that benefit all patients, such as smoking cessation counseling and comprehensive discharge instructions, are practiced reliably. “Hospitals that do this the best embed these tasks directly into the system, making them routine. We are moving toward that model,” says Fitzgerald.
For patients who are diagnosed with CHF, Baystate’s electronic medical record system helps prompt appropriate orders. “We have computerized physician order entry, so when a doctor puts in ‘heart failure’ the system enters an order set,” she explains. With prompts, the doctor chooses the appropriate medications — ACE inhibitor or ARB — based on the results of the left-ventricular heart function assessment.
Because the flu and pneumococcal immunizations recommended for CHF patients are important preventive measures for everyone, all patients are offered these shots as part of their routine admission process. “When patients are admitted, the nurse checks the record for immunizations or allergies, and asks patients who haven’t been immunized if they want to be,” says Fitzgerald. “If they say yes, then the orders are put in, and the doctor must have a rationale to discontinue the order.”  
The same is true for all patients (with or without CHF) who say they are smokers. “We flag them on admission, and three things happen,” says Fitzgerald. “First, the nurse provides counseling and documents it. Second, since they can’t smoke in the hospital, we ask if they’d like to begin nicotine replacement therapy. And third, we ask if they want to meet with Pulmonary Rehab to talk about smoking cessation.” Baystate has driven its smoking cessation counseling rate to 100 percent.
Discharge instructions are critically important for patients with CHF, who will be responsible for monitoring their health and working with clinicians to make appropriate adjustments in diet or even medications once they return home. But here again, Baystate saw a broader opportunity for improvement. “We realized we weren’t doing a terrific job,” says Fitzgerald. So Baystate developed better discharge information for all patients, shared on admission. “That way, patients can review the recommendations while they’re in the hospital, where they can easily ask questions,” says Fitzgerald. The instructions are then customized to match each patient’s needs and reviewed again prior to discharge.

Transitions Home
The importance of patients with CHF having a roadmap to follow at home can’t be emphasized enough. Those who lack the information, resources, or the support to manage their condition outside the hospital tend to bounce back in. And other factors can also create difficulties. “We have found that some patients are at higher risk for readmission,” says Elizabeth Popwell, CPHQ, FACHE, Safety Officer and Vice President of Systems Management at Cleveland Regional Medical Center (CRMC). These may be patients who can’t afford their medications, don’t have the means to buy or access healthy foods, or don’t possess the literacy skills to monitor and manage CHF on their own.
Seeing a need, CRMC asked its community case management department, Care Solutions, to add CHF patients to its programs. Care Solutions sends care managers to patients’ homes to assess their needs and provide customized health monitoring and education. “We take resources into the home, and learn about patients’ barriers and issues,” says Popwell. “Heart failure requires such a lifestyle change, and the staff is out there to help patients manage a care plan that is individualized to their environment and resources.”
Dotty Leatherwood, CRMC’s Vice President of Communications, Marketing and Outreach, says the program has helped to reduce the hospital’s readmission rate for its nearly 600 CHF patients each year from a rate of 25 percent per year to below 10 percent. “It’s made a big difference for individual patients, and for the CHF population overall,” she says. Care Solutions’ staff also worked with local nursing homes and home health agencies to standardize the education they receive. “Just because they leave the hospital doesn’t mean we leave them.”
St. Luke’s Hospital in Cedar Rapids, Iowa, part of the Iowa Health System, has for some time focused on effective discharge planning for patients with CHF. St. Luke’s redesigned its discharge process as part of its work with Transforming Care at the Bedside, a partnership between IHI and the Robert Wood Johnson Foundation. IHI’s How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure describes the work at St. Luke’s (along with some other hospitals) to illustrate the four main components that can help patients with CHF safely leave the hospital: 
  • Enhanced admission assessment for post-discharge needs, by a comprehensive care team, and including medication reconciliation
  • Enhanced teaching and learning, both for patients and family caretakers
  • Patient- and family-centered handoff communication, whether the patient is returning home or to a long-term care facility, including medication reconciliation
  • Post-acute care follow-up, including a face-to-face visit at home and/or with a doctor, within 48 hours of discharge
St. Luke’s Transitions Home program specifically includes clearly written information given to patients on admission; a patient-education technique called “Teach Back,” used with patients in the hospital and after discharge; and follow-up care that includes a home visit with a nurse within 48 hours of discharge, a physician office visit within three to five days, and a telephone call on Day 7 from an advanced practice nurse. The hospital also offers weekend classes on heart failure management and diet, designed to anticipate patients’ need for ongoing reinforcement and support.
Teach Back entails asking patients to repeat back in their own words what they have learned. Clinicians are trained to use this technique in a way that does not feel to the patient like a test, but rather a double-check on how well the clinician has explained things.
“We use the same set of questions across the continuum,” says Peg Bradke, RN, MA, Director of Heart Care Services at St. Luke’s. These are:
  • What is the name of your “water pill”?
  • What weight gain should you report to your doctor?
  • What foods should you avoid?
  • What symptoms should you report to your doctor?
Currently, Bradke says the Teach Back rate of correct patient responses is greater than 80 percent.
The written materials are short and clear, says Bradke. “We looked at our health literacy information, and asked ourselves how we could succinctly get across the information we want patients to know, and how to make it visual,” she says. Using feedback from focus groups, the heart failure improvement team, which included a patient’s family member, designed simple information packets using a “green-yellow-red zone” graphic showing patients how to interpret daily symptoms. Patients are also given refrigerator magnets with information about when to call the doctor.
Critical Information Refrigerator Magnet
The program is bringing St. Luke’s heart failure readmission rates steadily down. Says Bradke, “Our monthly CHF readmission rates are half of what they were prior to the implementation of the new transition home process.”

Technology at Home
New technology is also playing a key role in keeping CHF patients out of the hospital. Kaiser Permanente is piloting a program at two of its California locations that combines more intensive human support with advanced technology for home monitoring.
“We have Transition Nurses whose sole job is to discover CHF patients when they are in the hospital, even patients who may not have been given that label,” says Philip Madvig, MD, Associate Medical Director of The Permanente Medical Group in Oakland, California.
Invaluable to this process is Kaiser’s CHF registry, possibly because Kaiser is an integrated system, managing patients both in and out of the hospital. The registry includes all Kaiser patients known to have CHF. So, in addition to identifying hospitalized CHF patients by looking at “red flag” tests and medications, Transition Nurses can run a cross-check of hospitalized patients with the CHF registry. 
“Once they find these patients, they get directly involved in educating them and their families in the hospital, and also carry out medication reconciliation,” says Madvig. They manage the patient’s transition to ambulatory care, staying in touch with them for several weeks after discharge, helping them get follow-up appointments or referring them to disease management programs. “The nurses stay generally engaged with these patients for two to four weeks after discharge to assure that everything is falling into place and to make sure that unmet needs are addressed,” says Madvig.
Some patients in these pilot programs are referred to a home telemonitoring program, which involves training them on the use of a device that measures their weight, blood pressure, heart rate, and even blood glucose if they are also diabetic.
The patients use the device each morning, and data is automatically transmitted by modem to a call center monitored by nurse case managers. The software sorts the data, putting first on the list any patients whose data falls outside acceptable parameters defined by their doctors. “This is extremely useful,” says Madvig. “The nurse’s attention is immediately drawn to the patients in trouble, and she contacts the patient to advise him or her on medication or diet changes within a range already outlined by the doctor.” The nurse can also contact the patient’s doctor if necessary.
Madvig reports that this careful daily monitoring not only keeps the patient on target with medication and diet, but also serves as a training tool. “Of equal value is that patients develop a more sophisticated understanding of their own circumstances and how to make adjustments.” Most use the device for three to four months.
Madvig says that the two Kaiser centers that have piloted this program have cut the rate of hospitalization and readmission for CHF patients to about a third of the average rate system-wide. “This was not a controlled experiment, the patients weren’t randomized, but there is nothing else to explain this dramatic change,” says Madvig.
Kaiser is currently in the process of implementing the program in all 16 of its Northern California hospitals, and other Kaiser regions are watching and learning from the Northern California experience, says Madvig, with an eye toward integrating this program into their own CHF programs as appropriate.
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