A case management program targeted health improvements among congestive heart failure (CHF) patients and succeeded in cutting readmission rates to half the national average.

  • CHF program involved collaboration between Innovation Care Partners, Life Care Centers of America, and Assisted Home Health and Hospice.
  • The three organizations worked together to provide consistent CHF health education to patients.
  • Their goal was entirely about improving patient care quality.

Close to one in four people with congestive heart failure (CHF) are readmitted to the hospital, — a rate that must be improved. Several healthcare organizations are working together to provide consistent case management and education of CHF patients. Their efforts are successful, quickly resulting in a readmission rate of 12.2% — about half of the average rate.

“The heart failure readmission rate decreased by 50% in the skilled nursing facility [SNF] setting at three settings in the pilot program,” says Karen R. Vanaskie, DNP, MSN, RN, senior network director, care management program at Innovation Care Partners (ICP) in Scottsdale, AZ. ICP is a physician-led clinical integration network and accountable care organization (ACO) that works to reduce healthcare costs through community collaboration.

It took a team of healthcare organizations to successfully reduce CHF readmission rates. One contributor was a skilled nursing facility provider, Life Care Centers of America in Phoenix.

“We made a determination that in order for our patients to get the best outcomes possible, we needed to vet home health agencies to pick partners with similar goals,” says Richard Lasota, RN, CCM, division director of business development for Life Care Centers of America.

Life Care Centers of America decided to work with Assisted Home Health and Hospice in Scottsdale, AZ.

The home health agency started a telehealth program in California a couple of years earlier and followed it up with a telehealth program in Arizona, says Darryl Lerner, Arizona director of business development for Assisted Home Health and Hospice.

“We did a model with three other hospitals in Scottsdale including 68 patients, and only one patient had gone back to the hospital,” Lerner says.

There was an interesting trend that Lerner uncovered: “I noticed that patients who couldn’t go home immediately from the hospital were not sent to a skilled nursing facility when they were discharged because the hospital didn’t want them to come right back,” he says.

“The best programs are born out of necessity,” Lerner adds. “So, this was an opportunity.”

The opportunity brought Lerner and Lasota together to discuss continuity of care and moving patients from the SNF to home with home healthcare.

“We compared notes and discovered Life Care had a CHF program, and Assisted Home Health had a CHF program,” Lasota says. “We said, ‘Why not combine efforts and use the same educational material throughout their stay, so it would be consistent?’”

They theorized that a combined focus on educating CHF patients consistently would succeed at helping patients remain healthy outside of the hospital setting. The following is how the collaboration and coordination worked:

• Get all providers on board with CHF education. ICP was ready to assist with the collaboration and care continuity.

“Karen immediately saw its potential and started working with Innovation Care Partners care managers in the hospital, and that’s how the program gained momentum,” Lerner says.

The patient education around CHF was consistent from the hospital setting through the nursing facility and at home with home health. ICP, Life Care Centers, and Assisted Home Health have no financial interest in each other’s businesses.

“The interest we have is in better patient outcomes,” Lasota says. “We’re three companies that are trying to put our heads together with the ultimate goal of getting the hospital, home health, and the skilled nursing facility all on the same educational platforms.”

From the ACO’s perspective, the goal is to break down the silos and start taking care of patients to achieve better outcomes, Vanaskie says.

• Choose best practice educational strategies. The melded CHF program gives patients a manual or diary that includes educational information about their conditions and when to call the doctor or home health agency, as well as blank spaces where patients can record their vital signs, Lasota says.

“We teach different aspects of CHF and what patients need to do to take care of themselves and to remain healthy,” he adds. “Our nurses and staff at the SNF take education sheets with all different educational points to teach patients.”

The educational sheet has space that the clinician can mark to indicate whether the patient understood that section.

“If there’s an item the patient doesn’t understand, or if they forget a certain point we’re trying to get them to work on, then our nurses or staff will mark an ‘R’ on the sheet,” Lasota explains. “This means ‘reteach.’ Then, they go home and take that manual with them, and when the home health nurse visits, that nurse can open the manual and see what needs to be retaught.”

• Closely coordinate at discharge. Life Care Centers now prepares for a patient’s discharge from the SNF soon after the patient is transferred from the hospital setting. “We call home health and put everything together for the patient,” Lasota says.

Life Care Centers makes a referral to home health when the patient is admitted to the SNF, even if the patient will be there for a week or longer.

The early referral gives the patient and patient’s family time to meet and get to know the home health nurse, and it reduces the number of patients who refuse home healthcare, Lasota says.

This is important from a quality of care perspective because patients who are discharged home have a better chance of not being readmitted to the hospital if they receive home health services soon after they are sent home.

“Before we made this change, people would stop home health because they didn’t want people they didn’t know coming to their house,” Lasota explains. “This allows home health to prepare for that patient, and we also have ICP transitional care managers in our facility, helping with the transition and getting documents and information to the primary care physician’s office.”

“ICP created a transitional care management program,” Vanaskie adds. “We have nurses in the hospital and licensed social workers in post-acute settings.”

Post-acute transitional care managers are ICP employees who are placed in SNFs with whom ICP has a preferred provider relationship. These transitional care managers collaborate with skilled nursing facilities and the case management team, attending case reviews and communicating with case managers in SNFs, she explains.

The care managers stay with patients until they’re handed off to a transitional team in the post-acute setting or, if the patient returns home, they are followed for 30 days, Vanaskie says.

“The transitional team is critical,” she says. “It has not been in healthcare a long time, and we underestimate its impact on keeping patients stable after they leave the acute setting.”

• Collaborate to navigate past problems. The collaboration is seamless from the patient’s perspective. For example, a patient who has been discharged home, has a potential failure. The person’s level of awareness has changed, and the patient is not as active as he or she was. Maybe the patient is no longer able to transfer from the bed to a chair, as he or she had done when discharged from the skilled nursing facility, Lerner says.

“If we allow that situation to continue, the patient might fall or have another problem and end up in the hospital,” he says.

“There are patients who need to go to the emergency room, and we’ll send them,” he notes. “But if they’re not doing well and have a problem that can be managed at the skilled nursing facility, we’ll call the SNF nurse supervisor and, within one hour, we’ll get the patient from home to the SNF that the patient was discharged from.”

In that situation, the patient needs to be monitored closely, and with a little more time in the SNF the patient could succeed at discharge, he adds.

“People have to put the energy and time into making things better,” Lerner says. “Otherwise, they’re working in dysfunction.”

The key is to constantly adjust practices, making them better, he says.

• Work with patients and families to prevent rehospitalizations. One of the problems Lerner has noted involves a patient who has a minor crisis, causing the family to panic and send the patient to the ED — without first notifying the home health agency.

“Our nurse finds out and says to the family, ‘Try to call us first so we can do some triage or intervention, rather than defaulting to 911,’” Lerner says.

Often, these are health issues that the home health agency can easily manage. Or, the home health agency can send the patient to the SNF for monitoring.

“The more we communicate, the better the outcome,” Lerner notes.