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Hudson Valley Hospital Hudson Valley Hospital Center Heart Failure Center Heart Failure

ProjectProjectA collaborative approach to A collaborative approach to improving heart failure careimproving heart failure care

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Hospital to Home (H2H)Hospital to Home (H2H) A national quality improvement initiativeA national quality improvement initiative

Sponsored by the American College of Cardiology Sponsored by the American College of Cardiology (ACC) and the Institute of Healthcare (ACC) and the Institute of Healthcare Improvement (IHI)Improvement (IHI)

Purpose: to reduce cardiovascular-related hospital Purpose: to reduce cardiovascular-related hospital readmissions & improve transitional care from readmissions & improve transitional care from hospital to homehospital to home

Strategic partnerships are encouraged as a Strategic partnerships are encouraged as a vehicle for improving care and outcomesvehicle for improving care and outcomes

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HVHC Heart Failure Task HVHC Heart Failure Task ForceForce

Purpose: To improve Purpose: To improve the care delivered the care delivered to heart failure to heart failure patients across the patients across the continuum continuum

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Members of the HVHC HF Task Members of the HVHC HF Task ForceForce

Myrna Cuevas RN, EsqMyrna Cuevas RN, Esq William Higgins MDWilliam Higgins MD Maggie Adler RN-CMaggie Adler RN-C Jennifer Fell RDJennifer Fell RD Ann Marie Beall DPhAnn Marie Beall DPh Visiting Nurse Association of Hudson Visiting Nurse Association of Hudson

ValleyValley

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ACE Star ModelACE Star Model

ACE Star Model & EBP ACE Star Model & EBP ProcessProcess

PICO Question:PICO Question:

What interventions for heart failure What interventions for heart failure patients help decrease their patients help decrease their rehospitalization and mortality rates?rehospitalization and mortality rates?

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Knowledge Discovery & Evidence Knowledge Discovery & Evidence SummarySummary

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Facts on Heart FailureFacts on Heart Failure 50% readmission 50% readmission

rate within 6 rate within 6 months months

25% to 35% 25% to 35% incidence rate of incidence rate of death at 12 months death at 12 months

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Facts on Heart failure Facts on Heart failure The mortality rate The mortality rate

for women with for women with breast cancer is 1 breast cancer is 1 in every 29 deaths, in every 29 deaths, the mortality rate the mortality rate for women with for women with cardiovascular cardiovascular disease is 1 in disease is 1 in every 2.4 deaths every 2.4 deaths

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Trends in Hospitalization for Trends in Hospitalization for Heart Failure by Age Group Heart Failure by Age Group

1979-20041979-2004(CDC, 2006)(CDC, 2006)

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CMS Quality Measures: CMS Quality Measures: Heart Failure (HF)Heart Failure (HF)

100% compliance with the following evidenced-100% compliance with the following evidenced-based guidelines:based guidelines:

Discharge instructionsDischarge instructions dietdiet MD f/uMD f/uweight monitoringweight monitoringworsening s/sworsening s/sMedications with reconciliationMedications with reconciliation

Left ventricle systolic function evaluationLeft ventricle systolic function evaluation ACEI/ARB for LVSDACEI/ARB for LVSD Smoking cessation counselingSmoking cessation counseling

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Heart Failure at HVHC Heart Failure at HVHC Heart failure is the second highest DRGHeart failure is the second highest DRG Average costs per patient per day Average costs per patient per day

$2,000 $2,000 Average LOS is 6 daysAverage LOS is 6 days 30 day readmission rate is 24.2%, 30 day readmission rate is 24.2%,

national rate is 24.5% (HHS, 2008)national rate is 24.5% (HHS, 2008) Mortality rate is 9.7%, nationally it is Mortality rate is 9.7%, nationally it is

11.1% (HHS, 2008)11.1% (HHS, 2008)

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Translation into practiceTranslation into practice

Clinical Expertise to translate your findings into practice

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How can we improve How can we improve practice?practice?

Standardize treatment plans for heart failureStandardize treatment plans for heart failure Standardize patient education for heart Standardize patient education for heart

failurefailure Case Management referral for heart failure Case Management referral for heart failure

patients to Telehealth program at VNApatients to Telehealth program at VNA Collaborate with the Visiting Nurse Collaborate with the Visiting Nurse

Association of Hudson Valley (VNA)Association of Hudson Valley (VNA) Collaborate with community based Collaborate with community based

physiciansphysicians

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IntegrationIntegration

Integrating your findings into practice

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Standardize TreatmentStandardize TreatmentEvidenced-basedEvidenced-basedRecommendationsRecommendationspromotepromotea reduction ina reduction inrehospitalization andrehospitalization andmortality for patientsmortality for patientswith heart failure with heart failure (IHI, AHRQ, ACC)(IHI, AHRQ, ACC)

Physician Order SetPhysician Order Set LVSF assessmentLVSF assessment ACEI or ARBsACEI or ARBs Beta BlockersBeta Blockers Anticoagulants for atrial Anticoagulants for atrial

fibrillationfibrillation DiureticsDiuretics Lab assessmentLab assessment Influenza & Pneumoccocal Influenza & Pneumoccocal

vaccinationvaccination Diet and fluid restrictionDiet and fluid restriction Daily weightsDaily weights Exercise/activity toleranceExercise/activity tolerance Smoking cessation counselingSmoking cessation counseling Patient educationPatient education Case management & Nutrition Case management & Nutrition

referralreferral

(ACCF/AHA, 2009; AHRQ, (ACCF/AHA, 2009; AHRQ, 2009)2009)

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Considerations in Treatment of Considerations in Treatment of Special Populations Special Populations

Elderly patient's have an altered ability to Elderly patient's have an altered ability to metabolize or tolerate medication therapymetabolize or tolerate medication therapy

Isosorbide dinitrate and hydralazine is Isosorbide dinitrate and hydralazine is recommended for African-Americans in recommended for African-Americans in addition to standard heart failure treatmentaddition to standard heart failure treatment

50% of Asian patients develop a ACEI induced 50% of Asian patients develop a ACEI induced coughcough

Majority of patient’s with heart failure are Majority of patient’s with heart failure are womenwomen

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Standardize Patient Standardize Patient EducationEducation

Provide education literature from the AHAProvide education literature from the AHA Document education completed in EHRDocument education completed in EHR Revise Discharge Instruction sheet to Revise Discharge Instruction sheet to

include HF care instructionsinclude HF care instructions HF education reinforced by VNA nursesHF education reinforced by VNA nurses Future:Future: In CPOE create notification link from In CPOE create notification link from

physician order for HF education to nurses physician order for HF education to nurses task listtask list

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Heart Failure (HF) Screening Flow Heart Failure (HF) Screening Flow ChartChart

Present to ED

Case Manager

assesses patient for homecare or

skilled nursing need.

Y

N

No Health Care Services Provided

N

Homecare or skilled nursing referral made

YCase management evaluates patient/

Family/caregiver’s goals

Collaborates discharge plan with patient and

health care team

HF symptoms w/i 1 year

and/or present HF symptoms

and/or R/A 31 days

with previous HF diagnosis

Admit as Inpatient

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Telehealth ProgramTelehealth Program Screening for eligibility will be performed by Screening for eligibility will be performed by

the VNA while the patient is hospitalizedthe VNA while the patient is hospitalized Remote home monitoring will include vital Remote home monitoring will include vital

signs, oxygen level assessment, and weightsigns, oxygen level assessment, and weight Patient education provided by VNA nurses Patient education provided by VNA nurses

will reinforce education provided by HVHC will reinforce education provided by HVHC nursesnurses

Telehealth visits are in addition to regular Telehealth visits are in addition to regular home nursing visitshome nursing visits

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Accomplishments & Outcomes of Accomplishments & Outcomes of the the

Heart Failure ProjectHeart Failure Project Interdisciplinary Interdisciplinary

approachapproach Physician Order SetPhysician Order Set Patient EducationPatient Education Comprehensive Comprehensive

discharge instructionsdischarge instructions Telehealth programTelehealth program Collaboration across Collaboration across

the continuum of carethe continuum of care

Increase in patient Increase in patient self-management self-management skillsskills

Increase in patient Increase in patient satisfactionsatisfaction

Decrease variation in Decrease variation in care deliveredcare delivered

Decrease LOS from 6 Decrease LOS from 6 to 4 daysto 4 days

Decrease 30 day Decrease 30 day readmissions to 16%readmissions to 16%

Decrease mortality by Decrease mortality by 10%10%

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EvaluationEvaluation

HF Readmission & Mortality rates

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Heart Failure ReadmissionsHeart Failure ReadmissionsHeart Failure Task Force UpdateHeart Failure Task Force Update:: Total 27 HVHC patients referred Total 27 HVHC patients referred

to Visiting Nurse Association to Visiting Nurse Association Hudson Valley in 10 months (9/09 Hudson Valley in 10 months (9/09 – 06/10)– 06/10)– Readmission rate: 11%Readmission rate: 11%– HVHC Goal: 16%HVHC Goal: 16%

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Future Opportunities for Future Opportunities for CollaborationCollaboration

8.08%

15.89%

13.25%

10.62%

9.67%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

Routine-Home/Self Care

To SNF To Home CareService

Total for ThreeAreas

Total for AllReadmissions

Readmission Rate

Pinnacle Group:- HVHC- SSMC- MVH

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Improving Care at HVHCImproving Care at HVHC At HVHC we are At HVHC we are

dedicated to dedicated to caring for our caring for our patients across patients across the the continuum…….continuum…….

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References References Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP: Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP:

ACE Star Model of EPB: Knowledge Transformation. The University of Texas ACE Star Model of EPB: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. Retrieved July 8, 2009, from Health Science Center at San Antonio. Retrieved July 8, 2009, from http://www.acestar.uthscsa.edu

Centers for Disease Control and Prevention. (2006). Centers for Disease Control and Prevention. (2006). Heart Failure Fact SheetHeart Failure Fact Sheet. . Retrieved August 16, 2009, from the CDC on the World Wide Web: Retrieved August 16, 2009, from the CDC on the World Wide Web: http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf

Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2005). T. G. et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the management of chronic heart failure in the adult: A report of the American College of Cardiology/American heart Association Task Force American College of Cardiology/American heart Association Task Force on Practice Guidelines.on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACCmaxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FIRSTINDEX=0&resourcetype%2FAHA+2005+Guideline+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT=HWCIT

Institute for Healthcare Improvement (2008). Institute for Healthcare Improvement (2008). 5 Million Lives. Getting started 5 Million Lives. Getting started kit: Improved care for the patients with congestive heart failure.kit: Improved care for the patients with congestive heart failure. Retrieved July 19, 2009, from IHI on the World Wide Web: http://www.ihi.orgRetrieved July 19, 2009, from IHI on the World Wide Web: http://www.ihi.org

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ReferencesReferences Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al.

(2009). (2009). 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of management of heart failure in adults: a report of the American College of Cardiology foundation/American Heart Association Task Force on Practice Cardiology foundation/American Heart Association Task Force on Practice Guidelines.Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/119/14/1977?http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=2009+Focused+Update&seamaxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCITrchid=1&FIRSTINDEX=0&resourcetype=HWCIT

National Guideline Clearinghouse. (2007). National Guideline Clearinghouse. (2007). Heart Failure in AdultsHeart Failure in Adults. Retrieved July 20, . Retrieved July 20, 2009, from NGC on the World Wide Web: 2009, from NGC on the World Wide Web: http://www.guideline.gov/summary/summary.aspx?http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+AND+Failuredoc_id=11531&nbr=005972&string=heart+AND+Failure

Schroetter, S. A., & Peck, S. D. (2008, April). Schroetter, S. A., & Peck, S. D. (2008, April). Women’s risk of heart disease: Women’s risk of heart disease: Promoting awareness and prevention-a primary care approachPromoting awareness and prevention-a primary care approach. . MEDSURG NursingMEDSURG Nursing, , 17(217(2), 107-113.), 107-113.

U. S. Department of Health and Human Services. (2009). U. S. Department of Health and Human Services. (2009). Hospital Compare-A quality Hospital Compare-A quality tool provided by Medicaretool provided by Medicare. Retrieved July 19, 2009, from HHS on the World Wide Web: . Retrieved July 19, 2009, from HHS on the World Wide Web: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IEversion=default&browser=IE%7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home %7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home