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Decreasing Heart Failure Readmission's among Elderly Patients with Cognitive Impairment by Engaging Family
S148 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 the use of ReDS technology was associated with decreased readmission rates, length of stay (LOS), and improvement in appropriateness of diuretic therapy in patients with CHF at our medical center. Methods: An IRB approved retrospective chart review of 112 hospitalized adult patients with acute HF was conducted to evaluate the use of ReDS technology on patient outcomes. The ReDS vest readings were used at admission to aid the diagnosis of acute heart failure and adjust diuretics therapy. A two month time frame was used to assess the outcomes before and after device implementation. Eligible patients admitted June 1st to July 31st in 2017 without the guidance of ReDS vest served as the control group and patients admitted June 1st to July 31st in 2018 with the guidance of ReDS vest served as the study group. Baseline characteristics such as ejection fraction, BMP results, age, gender, and home and discharge diuretic regimens were reviewed. Each ReDS group patient was matched to a control patient based on all three criteria: age (§10 years), LVEF ( or >40%), and serum creatinine at admission (§0.3 mg/dL). The primary endpoint of this study was the rate of 30-day readmission. Secondary endpoints included LOS, changes in diuretic therapy based on ReDS reading, and changes in diuretics therapy between prior to admission and at discharge. The McNemar statistical test and the Wilcoxon signed rank test were used to analyze the endpoints. Results: A total 56 patients in the ReDS group were matched to 56 patients in the control group. For the primary endpoint of 30 day heart failure readmission rates, there were 4 readmissions in the ReDS group and 10 readmissions in the control group [OR = 2.5 (95% CI: 0.78-7.97); P = 0.09]. For the secondary endpoint of LOS, ReDS group patients stayed an average of 5.2 days and control group patients stayed an average of 6.3 days (p = 0.02). Three patients out of the ReDS group had inpatient diuretics therapy changed due to their ReDS reading. Lastly, when the prior to admissions diuretics therapy was compared to discharge therapy, the ReDS group had 19 patients with new diuretic additions, 8 patients with dose increases of current diuretics, and one patient with both a new addition and increased dose. In the control group, 22 patients had new diuretic additions, 5 patients had dose increases of current diuretics, and one patient had both a new addition and increased dose. Conclusion: The use of the technology decreased the LOS for patients admitted for ADHF and was able to augment the clinician’s ability to guide therapy for some patients. However, future studies covering a longer time frame are warranted to further evaluate its role in preventing 30 day heart failure readmissions.
408 In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: Lessons Learned upon Completion of 3 Years in the Heart Failure Bundle Payment Care Improvement Initiative Nicole Orr1, Leah Nazarian2; 1Tufts Medical Center, Boston, MA; 2Genesis HealthCare, Kennett Square, PA Background: Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) have poor clinical outcomes despite immense resource utilization. CMS developed the Bundled Payments for Care Improvement (BPCI) program, providing shared savings to participating providers for 90-day episodes of care with the purpose of improving quality and lowering costs. SNF-based cardiology consultation for HF patients was shown in a pilot study to reduce costs and 90-day readmission rates over an initial 2-year enrollment period. This study evaluates the comparative impact of that SNF-based cardiologist-led HF program on readmission rates and costs after completion of 3 years in the BPCI Model 3 program. Methods: We performed a retrospective analysis using Medicare claims data of BPCIenrolled HF patients admitted to St. Joseph’s Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program (HFP). Data were collected from October 2015 to September 2018. Readmission rates and cost savings vs CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs: 24 of which had no HFP; 7 of which had a HFP employing dietary, rehabilitation, social work and medical staff, with limited to no direct cardiology consultation. Cardiology consultation was requested for HF patients at SJC with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitation. Weekly cardiology rounds provided HF management within the context of achieving clinical stability, rehabilitation goals and preparing for community discharge. The cardiologist identified patients at high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results: There were 835 total HF episodes in the 3-year evaluation period: 22 were admitted to SJC; 291 were admitted to facilities with a HFP; and 522 to facilities without a HFP. The case mix at SJC included more patients with major complications and co-morbid conditions (77% vs 65% for all other SNFs, and 60% for SNFs with a HFP). Compared to other facilities, hospital readmission from SJC was significantly lower in the first 30 days after HF hospitalization (4.5% vs 23.6% (p = .018) for all other SNFs; and 23.7% (p = .019) for SNFs with a HFP), and remained lower for the 90-day episode duration (27.3% vs 44.8% (p = .052) for all other SNFs; and 48.8% (p = .026) for SNFs with a HFP). SJC achieved a higher margin of cost savings compared to facilities without a consulting cardiologist (28% vs 11%). Conclusions: Incorporating a cardiologist into SNF HF teams consistently reduced rehospitalizations and costs for HF episodes over a 3-year period. Further evaluation is needed to understand why outcomes among SNFs with standard HF programs were worse despite a lower case mix complexity. Weekly assessments and clinical management incorporating patient-centered rehabilitation goals may improve outcomes for this vulnerable HF population.
409 Decreasing Heart Failure Readmission’s among Elderly Patients with Cognitive Impairment by Engaging Family Michael T. Pudlo1, Susan Bionat2, Kathryn Agarwal2, George E. Taffet2, Arvind Bhimaraj2; 1Houston Methodist Hospital, Houston, TX; 2Houston Methodist Hospital, Pearland, TX Background: Higher 30-day readmission rates have been documented in older patients with cognitive impairment (CI) and heart failure (HF). Objective: To determine whether readmission rates are related primarily to HF severity or may be modified by inclusion of caregivers in nursing discharge education. Methods: Prospective QI program of cognitive testing and inclusion of caregivers in discharge education. Retrospective chart review for outcomes. Setting: Academic tertiary care hospital, two cardiovascular units with enhanced discharge education program. PARTICIPANTS: 232 patients age greater than 70 with diagnosis of HF screened for CI with documentation whether education included caregivers. Individuals with ventricular assist devices, transplant, or hospice excluded. INTERVENTIONS: Patients were screened for CI using Mini-Cog, if score < 4, nurses asked to include caregivers in discharge education. MEASUREMENTS: Mini-Cog score, 30-day all cause readmission’s, factors in Readmission Risk Score (RRS), hospital utilization, BNP on admit, history of atrial fibrillation and hemodialysis. Results: No differences in measures of HF severity between those with normal and abnormal Mini-Cog (<4) and between those with CI who did /did not have caregivers instructed. In CI patients, involving caregivers in discharge teaching was associated with decrease in 30-day readmission rates from 35% to 16%. Readmission rate without CI was 14%. Limitations: Non-randomized QI program, no characterization of caregivers or education. Conclusions: Patients age greater than 70 with HF and CI had two-fold reduction in 30-day readmission rates when caregivers were involved in discharge education. No differences in HF severity were found in this group of HF patients with normal vs abnormal screens for CI using Mini-Cog. Identification of CI and targeted caregiver engagement appear to be critical in reduction of readmission rates for older HF patients.
410 A Longitudinal Comparison of Palliative Care Consults in HFpEF and HFrEF Patients Melissa I. Owen, Brittany Butts; Emory University, Atlanta, GA Background: Palliative Care is a holistic approach to improve quality of life in patients with potentially life-limiting conditions and is recommended for advanced heart failure patients. However, palliative care is still underutilized in this population. Additionally, care and prognostication differences exist between heart failure with preserved fraction (HFpEF) patients and heart failure with reduced ejection fraction (HFrEF) patients. Therefore, this study explored the trajectory of inpatient palliative care consults between these two groups. Methods: This study examined data from one healthcare system in the Southeastern United States. Data were analyzed from i2b2, which is an open source technology system to query de-identified data from electronic health records. Data were examined from 2011- 2018 and included presence of palliative care consults, type of heart failure, demographics (age, sex, and race), and mortality. Analyses included descriptive statistics and comparisons between groups. Results: A total of 37,665 encounters were analyzed (19,384 HFrEF and 18,281 HFpEF). Palliative care consults were lower in patients with HFpEF than HFrEF with 11.49% of patients receiving consults vs. 17.87% in 2018 respectively (p<.001). Palliative care consults also appear to be declining overall, after peaking in 2015 for HFpEF at 17.35% and HFrEF at 22.24% (Figure 1). There were no significant differences over time when factoring in race or sex. The mortality rate, as expected, was higher in patients who received palliative care, although overall mortality from heart failure is decreasing. Conclusions: This study found that differences exist in palliative care consult rates between patients with HFpEF and HFrEF. Future
Figure 1. Palliative Care Consults in Heart Failure Patients 2011-2018
408 In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: Lessons Learned upon Completion of 3 Years in the Heart Failure Bundle Payment Care Improvement Initiative Nicole Orr1, Leah Nazarian2; 1Tufts Medical Center, Boston, MA; 2Genesis HealthCare, Kennett Square, PA Background: Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) have poor clinical outcomes despite immense resource utilization. CMS developed the Bundled Payments for Care Improvement (BPCI) program, providing shared savings to participating providers for 90-day episodes of care with the purpose of improving quality and lowering costs. SNF-based cardiology consultation for HF patients was shown in a pilot study to reduce costs and 90-day readmission rates over an initial 2-year enrollment period. This study evaluates the comparative impact of that SNF-based cardiologist-led HF program on readmission rates and costs after completion of 3 years in the BPCI Model 3 program. Methods: We performed a retrospective analysis using Medicare claims data of BPCIenrolled HF patients admitted to St. Joseph’s Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program (HFP). Data were collected from October 2015 to September 2018. Readmission rates and cost savings vs CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs: 24 of which had no HFP; 7 of which had a HFP employing dietary, rehabilitation, social work and medical staff, with limited to no direct cardiology consultation. Cardiology consultation was requested for HF patients at SJC with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitation. Weekly cardiology rounds provided HF management within the context of achieving clinical stability, rehabilitation goals and preparing for community discharge. The cardiologist identified patients at high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results: There were 835 total HF episodes in the 3-year evaluation period: 22 were admitted to SJC; 291 were admitted to facilities with a HFP; and 522 to facilities without a HFP. The case mix at SJC included more patients with major complications and co-morbid conditions (77% vs 65% for all other SNFs, and 60% for SNFs with a HFP). Compared to other facilities, hospital readmission from SJC was significantly lower in the first 30 days after HF hospitalization (4.5% vs 23.6% (p = .018) for all other SNFs; and 23.7% (p = .019) for SNFs with a HFP), and remained lower for the 90-day episode duration (27.3% vs 44.8% (p = .052) for all other SNFs; and 48.8% (p = .026) for SNFs with a HFP). SJC achieved a higher margin of cost savings compared to facilities without a consulting cardiologist (28% vs 11%). Conclusions: Incorporating a cardiologist into SNF HF teams consistently reduced rehospitalizations and costs for HF episodes over a 3-year period. Further evaluation is needed to understand why outcomes among SNFs with standard HF programs were worse despite a lower case mix complexity. Weekly assessments and clinical management incorporating patient-centered rehabilitation goals may improve outcomes for this vulnerable HF population.
409 Decreasing Heart Failure Readmission’s among Elderly Patients with Cognitive Impairment by Engaging Family Michael T. Pudlo1, Susan Bionat2, Kathryn Agarwal2, George E. Taffet2, Arvind Bhimaraj2; 1Houston Methodist Hospital, Houston, TX; 2Houston Methodist Hospital, Pearland, TX Background: Higher 30-day readmission rates have been documented in older patients with cognitive impairment (CI) and heart failure (HF). Objective: To determine whether readmission rates are related primarily to HF severity or may be modified by inclusion of caregivers in nursing discharge education. Methods: Prospective QI program of cognitive testing and inclusion of caregivers in discharge education. Retrospective chart review for outcomes. Setting: Academic tertiary care hospital, two cardiovascular units with enhanced discharge education program. PARTICIPANTS: 232 patients age greater than 70 with diagnosis of HF screened for CI with documentation whether education included caregivers. Individuals with ventricular assist devices, transplant, or hospice excluded. INTERVENTIONS: Patients were screened for CI using Mini-Cog, if score < 4, nurses asked to include caregivers in discharge education. MEASUREMENTS: Mini-Cog score, 30-day all cause readmission’s, factors in Readmission Risk Score (RRS), hospital utilization, BNP on admit, history of atrial fibrillation and hemodialysis. Results: No differences in measures of HF severity between those with normal and abnormal Mini-Cog (<4) and between those with CI who did /did not have caregivers instructed. In CI patients, involving caregivers in discharge teaching was associated with decrease in 30-day readmission rates from 35% to 16%. Readmission rate without CI was 14%. Limitations: Non-randomized QI program, no characterization of caregivers or education. Conclusions: Patients age greater than 70 with HF and CI had two-fold reduction in 30-day readmission rates when caregivers were involved in discharge education. No differences in HF severity were found in this group of HF patients with normal vs abnormal screens for CI using Mini-Cog. Identification of CI and targeted caregiver engagement appear to be critical in reduction of readmission rates for older HF patients.
410 A Longitudinal Comparison of Palliative Care Consults in HFpEF and HFrEF Patients Melissa I. Owen, Brittany Butts; Emory University, Atlanta, GA Background: Palliative Care is a holistic approach to improve quality of life in patients with potentially life-limiting conditions and is recommended for advanced heart failure patients. However, palliative care is still underutilized in this population. Additionally, care and prognostication differences exist between heart failure with preserved fraction (HFpEF) patients and heart failure with reduced ejection fraction (HFrEF) patients. Therefore, this study explored the trajectory of inpatient palliative care consults between these two groups. Methods: This study examined data from one healthcare system in the Southeastern United States. Data were analyzed from i2b2, which is an open source technology system to query de-identified data from electronic health records. Data were examined from 2011- 2018 and included presence of palliative care consults, type of heart failure, demographics (age, sex, and race), and mortality. Analyses included descriptive statistics and comparisons between groups. Results: A total of 37,665 encounters were analyzed (19,384 HFrEF and 18,281 HFpEF). Palliative care consults were lower in patients with HFpEF than HFrEF with 11.49% of patients receiving consults vs. 17.87% in 2018 respectively (p<.001). Palliative care consults also appear to be declining overall, after peaking in 2015 for HFpEF at 17.35% and HFrEF at 22.24% (Figure 1). There were no significant differences over time when factoring in race or sex. The mortality rate, as expected, was higher in patients who received palliative care, although overall mortality from heart failure is decreasing. Conclusions: This study found that differences exist in palliative care consult rates between patients with HFpEF and HFrEF. Future
Figure 1. Palliative Care Consults in Heart Failure Patients 2011-2018