Exceptional CHF program is built on best practices, benchmarks

Program has reduced 90-day readmissions to 4%

In the three years since implementation, an Illinois health care network’s clinical quality improvement program for congestive heart failure (CHF) patients has reduced 90-day readmissions to almost an eighth of the national average for CHF patients. Advocate Health Care, a 180-site integrated delivery network based in Oak Brook, built the program around a careful analysis of CHF patient records (DRG 127) in 1992, which served initially as the baseline year. As the program matured, that baseline moved to 1994 for most of the program’s process measurements.

To establish baseline benchmarks, Advocate’s medical records department personnel gathered data on a host of measures from 1992 patient records. Among them were:

• number of chest X-rays per patient;

• number of patients for which arterial blood gases were measured;

• lengths of stay;

• cost/charges per case;

• whether patients were put on a low-sodium diet;

• types of medications prescribed in each case;

• whether patients were admitted with a previous or new CHF diagnosis;

• admission source;

• whether they were discharged to their homes or a nursing home;

• use of consultants;

• previous medical history;

• type of doctor in attendance (primary care or cardiologist).

What Advocate managers found was that they already had a pretty good system: 90-day readmissions were 16%, or half the national average of 30%, says Cindy Welsh, MBA, RN, clinical quality specialist and facilitator of the project. But there certainly was room for improvement. Advocate patients got more chest X-rays than national averages, while only 30% were put on angiotensin-converting-enzyme (ACE) inhibitors. A more appropriate level of usage for ACE inhibitors is for 70% of CHF patients, according to the Agency for Health Care Policy and Research in Rockville, MD.

The baseline benchmarks also showed that Advocate was high in its use of home care for CHF patients, which probably accounted for its low readmission rate, Welsh says.

The next step was to build on this program by identifying best practices, she says. To do this, Advocate established five multidisciplinary groups composed of respiratory therapists, home health specialists, quality managers, pharmacists, advanced practice nurses, primary care doctors, and cardiologists.

A physician advisory group, including primary care doctors and cardiologists from five hospitals in the system, validated best practices gleaned from literature searches, Welsh says. This group also approved the efforts of subcommittees formed to develop drug therapy, acute care, and patient education guidelines.

For example, the pharmacists were primarily responsible for the drug therapy guides, based on functional classes. But it was the physician advisory group, working in conjunction with the pharmacists, that grappled with whether to treat stage I or II patients with Lasix or digoxin.

The best practices then were incorporated into the program’s critical pathway. One particularly successful aspect that emerged from this exercise was the formulation of a transitional care segment. (See chart on the CHF transitional care program, p. 107.) Designed for those patients not discharged to home care, transitional care consists of telephone follow-up, outpatient visits, and monthly patient education classes. The 90-day readmission rate for a group of 49 patients in the initial transitional care group was just 4%, Welsh says.

She credits this low readmission rate to the transitional care program’s emphasis on outpatient follow-up and educational support. Patients receive a tele-management call 48 hours after discharge and again 10 days later to assess how they’re doing. Registered nurses use a prompting script to assess each patient’s diet, exercise, daily weight measurements, medication compliance, and general understanding of CHF.

The nurses make referrals to social services, schedule follow-up appointments, and arrange transportation if necessary. A "yes" answer to certain questions prompts the nurses to consult the patients’ physicians, who also receive a summary report of the call. Patients are scheduled to see their physicians in the first week and then to see the CHF coordinator at the local hospital two weeks after discharge.

The coordinator checks vital signs and weight and determines whether the patient needs additional individual follow-up or can be referred to group follow-up. Group education meetings are held monthly for patients and families. Speakers include nurses, cardiologists, dietitians, pharmacists, and staff from patient support services and cardiac conditioning.

"We have surveyed the patients in transitional care, and they report being satisfied with the fact that they learn better care for their illness as well as appreciate the support provided by others who have the same illness," Welsh says.

Benchmarks show steady improvements

Overall, the system, which sees more than 1,800 CHF patients a year, has seen a slight downward trend in its already low 90-day readmission rate and average length of stay, Welsh says. Some individual sites have reported significant decreases in these indicators, but the system’s average 90-day rate is down to 15% from 16% (half the national norm of 30% as reported by the Cardiology Roundtable), and the length of stay is 5.43 days, down from 5.53 days.

Welsh says physicians have reported that the CHF program has significantly decreased readmissions among their "frequent flier" patients. Patients report they are more satisfied with the level of education they receive and the support they find among other CHF patients.

"We had heard informally from clinicians and patients that there was a fragmented approach to care of CHF patients," Welsh says. "We are no longer focused on the hospital episode, but rather we are focused on the patient and how to provide continuity of care."

Updating the pathways

Clinical pathways were already in place in the five hospitals that began Advocate’s CHF program, but they needed to be updated. Each hospital was allowed to vary its tools to meet specific needs, but a template was devised based on a four-day length of stay with discharge on day five. Discharge guidelines were printed on the back of the pathways, encouraging clinicians to take into account patients’ ability to care for themselves, social support systems, and medical equipment needs.

The ability to tailor the program to the particular hospital is important, says Carol Main Benner, RN, MSN, the CHF coordinator at Good Shepherd Hospital in Barrington, IL, part of the Advocate system. At Good Shepherd, 95% of the patients receive a cardiac consult, so staff are well-versed in CHF and don’t need to use the clinical pathway routinely. Instead, they have taken it one step further by incorporating the information into routine doctors’ orders. "These are very complex patients," she says, "and we need to tailor the care for each individual."

A comprehensive education program was developed, including videos, a family education guide, and a pictorial brochure for poor readers. Also developed was a "refrigerator post-it," a one-page summary of reasons patients should call the doctor and things they need to do daily, such as take their pills and limit sodium. Patients are discharged with a form they can take to their next site of care that shows what they’ve already learned. The next caregiver can get a good idea of what the patient knows and build on that information.

"Our whole purpose was to help them understand how these actions can keep them out of the hospital," Welsh says. "We knew that patients are most often readmitted because of noncompliance: not taking their meds, not following their diet, not watching their weight."

Advocate uses a Transition Systems database to generate data for clinical quality improvement projects. The overall measure of success is the 30- and 90-day readmission rate, but the system also tracks average cost and charge per case, monitors telemanagement calls, and reports how many patients keep their follow-up appointments.

Ultimately, the database will allow Advocate to identify CHF patients when they enter the emergency department (ED) and provide ED staff with the patients’ latest labs, EKGs, medications, and other information. This will eliminate the "rediagnosing" of CHF patients that frequently takes place now. The program managers designed an identification card for CHF patients that would alert ED staff members they are dealing with a CHF patient, but the card hasn’t been very successful. "I don’t know if they already have so many cards they are confused, or we just didn’t do a good job educating them on using it," Welsh says.

The pilot program using the database, designed for class III and IV CHF patients, has just begun in one of Advocate’s clinics. Welsh hopes that it will provide new baseline benchmarks to keep pushing the program forward. Meanwhile, she fields a lot of calls from other institutions wanting to benchmark her program. She welcomes the insight they bring. "I always learn something from them," she says.

[Editor’s note: For more information, contact Cindy Welsh, MBA, RN, Advocate Health Care, 2025 Windsor Drive, Oak Brook, IL 60523. Telephone: (630) 572-9393.]