Discharge Planning Advisor

CHF project aims to bridge gap between providers

Goal is better outcomes, fewer readmissions

Drawing on 20 years of quality improvement experience, MPRO, Michigan's Health Care Quality Improvement Organization, is bringing together hospitals, home health agencies, and physician practices to come up with solutions to communications barriers between providers, with the ultimate goal of improving the outcomes for the state's cardiovascular disease patients.

"In the state of Michigan, no one has brought different groups from across health care setting together at one table. This pilot project is the first time that hospitals, home health agencies, and physician offices come together to work together for better patient outcomes," says Linda Charles, RN, BS, project coordinator for MPRO's hospital quality improvement team.

MPRO has been awarded a contract with the Michigan Department of Community Health for the pilot project "Cardiovascular Health Project." The goal is to reduce the number of hospital readmissions for patients with cardiovascular disease, especially congestive heart failure (CHF) by reinforcing education and self-management before and after hospitalization.

The project aims to improve the consistency of documentation, patient assessment, and reporting of clinical findings and to close the gap between the hospital, home health agencies, and physician offices.

"The goal of the heart failure collaborative across settings is not just to decrease readmissions. Other goals are to reinforce heart failure patient education and self-management prior to and after hospitalization and to help the patients gain more control over the disease process," says Teri Aldini, RN, MS, project manager for the home health and hospital team.

Heart failure is the leading diagnosis for Medicare patients in the state of Michigan and is among the leading diagnoses for hospital readmissions.

The 325,000 patients discharged with a diagnosis of heart failure last year incurred approximately $226 million in hospital costs. About 25% are discharged from Michigan hospitals with a home health referral.

"When we worked on cardiovascular quality improvement projects in the past, our team had observed the disconnect between the hospital, the home health agency, and the physician office. We wanted to create a collaboration between the hospitals and home health offices, realizing that the physician's office is an integral part of post-acute care," Charles says.

The disconnect appears to occur when patient care is managed by a cardiologist while the patient is hospitalized and following the patient's discharge home, care is then resumed by the primary care physician.

Typically, the cardiologist will discharge the patients to home with home health and the patient receives post-discharge instructions from the hospital but it takes a while for the discharge summary to reach the physician's office. If the patient has a question or an acute event or the home health agency calls for further orders, the physician does not have the information he or she needs to prescribe follow-up care.

"Even if a primary care physician assumes care in the hospital and writes a home health referral, he has the knowledge of what happened in the hospital but the office staff may not, and they are the ones who typically triage the patients," Charles says.

The project aims to integrate care across all settings to improve patient outcomes by bringing together hospitals, home health agencies, and representatives from physician offices for two intensive learning sessions during which the providers share ideas about improving communication.

"We serve as facilitators at these sessions, bringing different stakeholders together and giving them the opportunity to identify where the problems are and work on solutions to overcoming barriers. It's the responsibility of the providers to adapt the lessons they learned when we were together and change the process of care in their individual settings," Charles adds.

MPRO holds a monthly conference call in which participants report on what they have implemented.

Participants include hospital and home health quality improvement staff, home health administrators, hospital discharge planners and offices managers, and sometimes nurses from physician practices. The pilot project with the Michigan Department of Community Health involves two hospitals, three local home health agencies, and four physician practices.

The organization has led a number of other cardiovascular quality improvement initiatives, including the Michigan Heart Failure Discharge Documentation program, developed with Blue Cross and Blue Shield (BCBS) of Michigan and the Michigan chapter of the American College of Cardiology.

The aim of the project is to ensure that admission and discharge orders meet the Core Measures for quality established by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations.

The team brought together 39 participating Michigan hospitals for intensive learning sessions and sharing ideas to make sure the quality initiatives are being met.

"The goal of the program was not just to increase the rate of discharge instructions documentation but to increase patient knowledge and to give the patients more tools to help them control their disease process and adapt their lifestyles," Aldini says.

The hospitals received a template document designed to improve the documentation for the six core measures for heart failure and were encouraged to use it or adapt it.

MPRO followed up with conference calls in which hospitals reported their use of the tools provided.

As a result of the project, hospitals in Michigan have begun sharing tools that help them address the Core Measures and other quality initiatives, Aldini says.