Care Continuum Collaboration Improves Heart Failure Patient Care
By Melinda Young
A focus on multidisciplinary management of heart failure patients, along with transitional care interventions and integration with post-acute care facilities, can lower 30-day readmission rates for heart failure patients, new research shows.1
Researchers reviewed how partnerships with home health agencies and skilled nursing facilities could help prevent heart failure readmissions, says Purnima Krishna, DNP, MSN, MBA, RN, NEA-BC, study author and director of quality in the Cardiovascular Service Line at Stanford Health Care.
“It focuses on whether post-acute care collaboration is helpful in reducing readmission rates of heart failure patients,” Krishna explains. “We did a literature review on best practices on how organizations have tried this collaboration.”
It is challenging to find examples of successful collaborations because the more common model is for hospitals, home health agencies, and skilled nursing facilities to fall under one umbrella of governance, Krishna explains.
When acute and post-acute care facilities are integrated into one health system, it is easier to communicate, gather information, and navigate the continuum. Non-integrated facilities face more challenges with care coordination.
“What we learned is that the skill set of the clinical teams in post-acute care facilities can vary a lot,” Krishna says.
Krishna studied data from more than 90 post-acute care facilities to find information about how hospital collaborations were working. “What I found is the case managers from the acute care setting are very critical for this collaboration,” Krishna says. “Case managers already have a relationship with some of the post-acute organizations, and they can build upon that.”
Case management leaders can guide clinicians through information gaps, such as when patients transition to home with a home health agency assisting patients. For instance, a case management leader can create an electronic banner to highlight heart failure patients and to show clinicians their care plans. Case managers can send this information to collaborators, including skilled nursing facilities and home health agencies.
“The information is sent like an electronic fax to those agencies, and it’s more secure than email,” Krishna explains. “It says, ‘Heart Failure Patient’ in red color with a larger font, and it tells them to initiate their agency’s heart failure care plan.”
Communication like this helps collaborators identify patients early, and it prevents delays in treatment for heart failure patients. “Often, they get a progress note from the physicians and what type of treatment has been rendered here in the medical center,” Krishna explains. “It has a lot of information that physicians might not have time to read through.” The electronic banner captures their attention and ensures they see the most crucial information first.
Other tactics for developing successful care coordination collaborations include:
• Find the right partners. These are the questions to ask when beginning a collaboration:
- Who are our best performers?
- How much collaboration is needed?
- How much support do post-acute services need from the medical center?
“The other thing we learned is that in order for us to collaborate with non-integrated health systems, [we need to] make sure from the beginning that our goals are aligned,” Krishna says. “The leadership from the hospital side and post-acute side have to have shared goals.”
• Follow up on patients moved to post-acute care settings. Typically, home health agencies call new patients within 48 hours, but this does not always happen. Hospital case managers or heart failure RN coordinators can call patients to check whether they have heard from their home health agency.
Care coordinators also can contact skilled nursing facilities to ensure patients started their care plans and to address any barriers that arise. Care coordinators may ask patients these questions:
- How are you feeling?
- Are you experiencing any shortage of breath?
• Schedule a follow-up visit. Heart failure patients set follow-up appointments with the cardiologist or their primary care physician, typically within seven days.
“We also met with post-acute care facilities to see how many patients went to them within the last few weeks and what they did,” Krishna adds. “We asked about any barriers they may need help with.”
• Hold regular check-ins. “When we launched bi-weekly check-ins, we said, ‘In [the past] two weeks, how many patients were referred to you?’” Krishna says. “We were meeting with each of the home health agencies separately and with skilled nursing facilities individually.”
This resulted in 10 group virtual meetings every two weeks between the heart failure team at the medical center and the post-acute organizations.
“We were all on the call, and we’d share patient information ahead of time so they could review the case and come prepared for discussion,” Krishna notes. “We discussed two to three cases in a bi-weekly Zoom call.” The meetings went well, and everyone involved was well prepared, she says.
At first, participants provided too much detail. This was scaled back to a broader overview of logistics. “We had to manage the key elements we needed to discuss in those calls,” Krishna says. “They were 20 to 30 minutes, max.”
• Identify communication tactics. When collaborators are not part of the same health system, the hospital’s medical records cannot be shared easily with post-acute providers. One solution is to create an information technology messaging pool outsiders can access.
“We ask them to send us updates through the messaging pool,” Krishna says.
Collaboration processes can work with proper planning and implementation. This also can be done without hiring additional staff. “We had a heart failure clinical nurse specialist come to all meetings,” Krishna explains. “There also was a major time commitment from members, which included the quality director, the quality consultant, and the clinical nurse specialist.”
Although each member spent time as the program was built, that was only in the beginning. “All paths for sustaining this intervention are within their job function, and it will continue after the study,” Krishna says. “The heart failure team is pretty satisfied with the results so far.”
- Krishna P. Assuring a continuum of care for heart failure patients through postacute care collaboration: An integrative review. Prof Case Manag 2022;28:3-10.
A focus on multidisciplinary management of heart failure patients, along with transitional care interventions and integration with post-acute care facilities, can lower 30-day readmission rates for heart failure patients, new research shows.
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