CHF program drastically cuts readmission rates

Transitional care is key to results

In the two years since implementation, an Illinois health care network's clinical quality improvement program for CHF patients has developed a module that has reduced readmissions to almost an eighth of the national average.

Advocate Health Care, a 180-site integrated delivery network based in Oak Brook, began the program to provide better continuity of care and reduce costs for patients suffering from the expensive disease. Programs already in place had reduced readmissions for CHF patients to 15% - half the national average of 30%. But among Advocate patients who participate in the system's transitional care program, only 4% are readmitted to the hospital within one year, says Cindy Welsh, MBA, RN, clinical quality specialist and facilitator of the project.

She credits the transitional care program's emphasis on outpatient follow-up and educational support. Advocate developed the transitional care program to help patients comply with their physician's orders, Welsh says.

Patients in the program are identified with a CHF care card that alerts providers to their diagnosis, preventing duplication of previous work-ups. Patients receive a telemanagement call 48 hours after discharge and again 10 days later to assess how they're doing. Registered nurses use a prompting script to assess the patient's diet, exercise, daily weight measurements, medication compliance, and general understanding of CHF.

Transitional care closes a gap

The nurses make referrals to social services, schedule follow-up appointments, and arrange transportation if necessary. A "yes" answer to certain questions prompts the nurse to consult the patient's physician, who also receives a summary report of the call.

Patients are scheduled to see their physician 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. The group meetings are held monthly for patients and families with speakers including nurses, cardiologists, dietitians, pharmacists, staff from patient support services, and staff from cardiac conditioning. (See chart on the CHF transitional care program, p. 65.)

"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.

In addition to the transitional care program, other elements of the CHF project include:

· a clinical pathway for inpatient care and discharge guidelines;

· drug therapy guidelines;

· enhanced patient and family education;

· home health follow-up.

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, she says. Some individual sites have reported significant decreases in these indicators, but the system 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 receive from other CHF patients. "We had heard informally from clinicians and patients that there was a fragmented approach to care of CHF patients," she 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."

Advocate's process began with clinical subgroups charged with developing a specific product. The subgroups conducted background work, including a clinical literature search, patient chart abstracts, and polls of hospitals' best practices.

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 its specific needs, but a template was devised based on a four-day length of stay with discharge on day five. Discharge guidelines are printed on the back of the path, 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 path routinely. Instead, they have taken the path 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."

The patient chart abstract done in the background phase of the project revealed that ACE inhibitors were used in only 30% of patients, while Agency for Health Care Policy and Research guidelines say the drugs should be used in 70% of patients.

The drug subgroup found that physicians needed an efficient way to summarize current recommendations, and they devised a form listing four standard categories of drugs for CHF - diuretics, digoxin, ACE inhibitors, and vasodilators - and the appropriate usage information. As a result, 60% to 70% of Advocate's CHF patients are discharged on ACE inhibitors, Welsh says.

Improving patient and family education

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 why patients should call the doctor and tasks 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 Inc. 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. "You can never overcommunicate," Welsh says. "You can think you've told everybody, and there will always be someone who says they didn't know about it."