Discharging the Heart Failure Patient

Transcription

1 Discharging the Heart Failure Patient John Grider, DO, FACOI Department of Internal Medicine AT Still University of Health Sciences Hospitalist Northeast Regional Medical Center

2 Discharge priorities Preventing readmission Reducing mortality Encourage early and frequent follow up Prepare the patient psychologically for the disease, and the lifestyle changes they need to adopt

3 Reducing readmissions Care coordination programs Insurance/HMO driven Hospital driven Community driven Most readmissions occur before the first PCP followup visit ER driven readmissions prevention Hadi, A., Y. Hellman, A. S. Malik, M. Caccamo, I. Gradus-Pizlo and J. Kingery (2014). "Reducing heart failure readmission rates

4 Rates aren't changing Hall MJ, Levant S, DeFrances CJ. Hospitalization for congestive heart failure: United States, NCHS data brief, no 108. Hyattsville, MD:

5 Evolving Demographics

6 Disposition evolving

7 Pathways Program Coordinated by AHEC, RAIL, Truman State Univ. Exercise Science Department Medical student home visit 3 months of free supervised gym membership Sodium education visit Nurse follow up calls until primary care followup Bypass restrictive cardiac rehab enrollment/reimbursement requirements

8 What went wrong Patients were contacted after leaving the building Exercise was the deal breaker for most patients Patients see no disadvantage in readmission Referrals were optional EMR transition

9 What went wrong Patients were contacted after leaving the building Exercise was the deal breaker for most patients Patients see no disadvantage in readmission Referrals were optional EMR transition

10 ER-based readmissions reduction Dispatched a dedicated "advanced provider" to initiate aggressive diagnostics/therapeutics to try and prevent readmission Indiana University department of cardiology Hadi, A., Y. Hellman, A. S. Malik, M. Caccamo, I. Gradus-Pizlo and J. Kingery (2014). "Reducing heart failure readmis

11 Followup Will need more outpatient testing/services Kuo, Y. F. and J. S. Goodwin (2011). "Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study." Ann Intern Med 155(3): Should be seen (by PCP) within one week 61% of readmissions occur within 15 days Risk for death also highest earliest Dharmarajan, K., A. F. Hsieh, V. T. Kulkarni, Z. Lin, J. S. Ross, L. I. Horwitz, N. Kim, L. G. Suter, H. Lin, S. L. Normand and H. M. Krumholz (2015). "Trajectories of risk after hospitalization for heart failure, ac

12 Early follow up is necessary Median time to readmission is 12 days Dharmarajan, K., A. F. Hsieh, Z. Lin, H. Bueno, J. S. Ross, L. I. Horwitz, J. A. Barreto-Filho, N. Kim, S. M. Bernheim, L. G. Suter, E. E. Drye and H. M. Krumholz (2013). "Diagnoses and timing of 30-day read

13 Why the early readmission? Medication confusion Failure to recognize evolving comorbidity "tunnel vision" Patient/caretaker uncertainty about how to react to symptoms Inadequate pre-discharge education Weekend discharge increases risk of readmission McAlister, F. A., A. G. Au, S. R. Majumdar, E. Youngson and R. S. Padwal (2013). "Postdischarge outcomes in he (ahr, 0.71, 95% CI, )

14 The tune up... Core measures Seattle Heart Failure model Advance directives talk Nutritionist parting shot on dietary recommendations

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16 Seattle Heart Failure Model Well validated Free app / website Patient education tool Promote medication compliance Segue to advance directive conversation n.edu/shfm/

17 SHFM underestimates mortality Kalogeropoulos, A. P., V. V. Georgiopoulou, G. Giamouzis, A. L. Smith, S. A. Agha, S. Waheed, S. Laskar, J. Puskas, S. Dunbar, D. Vega, W. C. Levy and J

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19 Advanced directives Are you saying I'm going to die? Rate of advanced directives in patients admitted with heart failure only 12.7% Chaplain can help educate on process Should address code status at admission, AND at discharge Has improved HCAPS for "physician communication" scores Butler, J., Z. Binney, A. Kalogeropoulos, M. Owen, C. Clevenger, D. Gunter, V. Georgiopoulou and T. Quest (201

20 Reducing Mortality Non-cardiac causes of mortality in HfpEF Total 6mo mortality similar to HFrEF

21 Depression screening Incidence of depression in hospitalized heart failure patients is high (27% moderate-severe) Correlates with quality of life scores May influence readmission risk Hamo, C. E., J. F. Heitner, M. A. Pfeffer, H. Y. Kim, C. T. Kenwood, S. F. Assmann, S. D. Solomon, R. Boineau, J. L. Fleg, J. A. Spertus and E. F. Lewis (2015). "Baseline Distribution of Participants With De

22 Nutritionist review Within 24hrs of discharge Rehash the previous visits 2g sodium restriction Protein intake Alcohol abstinence Best done with the family present Improves dietary compliance (as measured by Dunbar, S. B., P. C. Clark, C. Deaton, A. L. Smith, A. K. De and M. C. O'Brien (2005). "Family education and support interventions in heart failure: a pilot study." Nurs Res 54(3): hr urine sodium)

23 Disposition Pearls Not all nursing homes will obey a sodium restricted diet order Home health is medicare covered for "medication teaching" Can be the safety net for medication list chaos Home health at discharge is associated with lower readmission rates (by almost half!) Madigan, E. A., N. H. Gordon, R. H. Fortinsky, S. M. Koroukian, I. Pina and J. S. Riggs (2012). "Rehospitalization in a nationa Fleming, M. O. and T. T. Haney (2013). "Improving patient outcomes with better care transitions: the role for home health." Cleve Clin J Med 80 Electronic Suppl 1: es2-6.

24 Type of home health matters Home telehealth cuts readmissions from 21% to 10% (vs. No home health) Thomason, T. et al (2015). "Home telehealth and hospital readmissions: a retrospective OASIS-C data analysis." Home Healthc Now 33(1): Nurse met patient in the hospital cut readmission risk from 27.7 to 15.9% (2011). "Coaching helps cut readmissions." Hosp Case Manag 19(10): Had diuretic protocol 10% readmission risk Veilleux, et al (2014). "Home diuretic protocol for heart failure: partnering with home health to improve outcomes and reduce readmissions." Perm J 18(3): Higher nursing visit intensity cuts readmission risk Madigan, et al (2012). "Rehospitalization in a national population of home health care patients with heart failure." Health Serv Res 47(6):

25 Discharge education 1-hr session with specialist heart failure nurse educator prior to discharge Reduced readmission rate (HR 0.65) Reduced cost of care by $2823 (p=0.035) Compared with staff nurse education at discharge Koelling, T. M., M. L. Johnson, R. J. Cody and K. D. Aaronson (2005). "Discharge education improves clinical outcomes in patients with chronic heart failure." Circulation 111(2):

26 Conclusion Effective prevention of readmission takes face time Home health coach Nurse educator Nutritionist Osteopathic physician Hospitalist Primary Care Emergency room

27 Conclusions Osteopathic physicians are well suited to treat heart failure patients Need to build rapport with patients, so they no that you care, especially about the details Need to be meticulous about patient care Medication reconciliation Discharge instructions Social / family support