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The use of the Seattle Heart Failure Model to Guide Palliative Care Referrals in Advanced Heart Failure
The 22nd Annual Scientific Meeting HFSA
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Introduction: Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge at our institution is the large volume of hospitalized Heart Failure (HF) patients (5,000/year) with historically high 30-day readmission rates (23%). Hypothesis: Development of a designated multidisciplinary HF team (MD, NP, PharmD, and CM) that integrates a risk stratification model with a standardized comprehensive pre/post discharge management plan will decrease 30-day readmission rates. Methods: May 1 - July 31, 2017 was the implementation phase of the HF-Readmission Reduction Initiative (HF-RRI) Pilot Project. During this time, approval of administrative leadership, credentialing of HF-NP staff, unit based RN and case management (CM) orientation, and inclusion of a designated PharmD specializing in HF was completed. August 1, 2017 began the HF-RRI process which included generation of a daily patient list with Primary HF (ICD-10) and their associated HOSPITAL (risk for readmission) Score. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients with an intermediate to high risk HOSPITAL Score were flagged for further in-depth pre-discharge HF NP consult/ PharmD counsel, post discharge CHF Clinic 7-day appointment and weekly telephone assessments. Retrospective review of prospectively collected data was analyzed based on age, gender, length of stay (LOS), NYHA, HOSPITAL Score and 30-day readmission. Time periods included Pre-HF-RRI (November 1, 2016 -April 30, 2017); Implementation Phase (May1, 2017-July31, 2017); Post HFRRI (August 1, 2017-January 31, 2018). Results: We identified 242 Primary HF patients (116-Pre-HF-RRI and 126 Post HF-RRI). Continuous variables (age, LOS and risk score) and categorical variables (age75+, gender, NYHA, and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank sum and chi-square tests, respectively. The groups were comparable on age and gender. There were no differences in LOS, NYHA or HOSPITAL score. The 30day readmit rate was statistically significantly lower in the POST HF-RRI group compared to the PRE HF-RRI group, 10.3% (12/116) vs. 20.6% (26/126), respectively, p=0.0279. Conclusion: Our newly integrated multidisciplinary HF team approach that incorporates a risk for readmission HOSPITAL Score stratification can prevent avoidable 30-day readmissions.
275 “Teach a Man to Fish”: Clinician Perspectives on Primary Palliative Care in Heart Failure Zachariah P. Hoydich1, Matthew Harinstein1, Beth Rose2, Bruce Rollman1, Kathryn Berlacher1, Dio Kavalieratos1; 1University of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA Purpose: Heart failure (HF) is a common, debilitating disease that decreases both longevity and leads to decreased quality of life. Palliative care is a clinical subspecialty, and overall approach to care, that emphasizes alleviation of suffering through symptom management, psychosocial support, and assistance with complex treatment decision-making. Despite recommendations from major cardiology societies, specialty palliative care remains underutilized in HF. Accordingly major cardiology societies have called for clinicians without specialty palliative care training to deliver basic palliative competencies (i.e., “primary” palliative care), such as symptom management and goals-of-care elicitation. It is unclear what non-palliative care specialists caring for patients with HF view as barriers and facilitators to delivering primary palliative care. Methods: We conducted semi-structured phenomenological interviews with physicians, nurses, and physician assistants caring for patients with HF across the United States, recruited through a snowball convenience sample. Interview topics included: 1) a hypothetical treatment strategy for an advanced HF patient with significant unmet palliative needs; 2) knowledge and attitudes regarding the role of both primary and specialty palliative care in HF; and, 3) barriers and facilitators of primary palliative care integration in standard HF management. Two analysts independently coded data using template analysis, a hybrid inductive/deductive qualitative technique. Results: We interviewed 18 clinicians: 4 physicians and 2 advanced practice providers from primary care, cardiology, and palliative care specialties. 61% were female, 89% Caucasian, average age was 43, and the median years in practice, 12. We identified several barriers to primary palliative care integration including 1) structural and organizational barriers like time constraints; 2) attitudinal barriers, such as discomfort addressing goals-of-care; and 3) educational deficits including a perceived lack of training in primary palliative care skills (e.g., symptom management, difficult communication). Clinicians of all non-palliative specialties interviewed desired training in these skills. Conclusion: Many clinician-perceived barriers to the provision of primary palliative care in HF may be addressed through education regarding symptom management and advance care planning communication. Others, such as time constraints and organizational barriers, may be reduced through normalizing and integrating palliative care as a natural facet of standard HF management. While clinician respondents endorsed integrating primary palliative care into routine HF care, randomized trials are needed to establish the effectiveness of primary palliative care interventions, including HF primary palliative care curricula.
277 The use of the Seattle Heart Failure Model to Guide Palliative Care Referrals in Advanced Heart Failure Judith Hupcey1, Lisa Kitko2, Windy Alonso3, Elizabeth Thiede2; 1Penn State University, Hershey, PA; 2Penn State University, University Park, PA; 3University of Nebraska Medical Center, Omaha, NE Introduction: Of the over 6 million individuals living with heart failure (HF) approximately 5% or 300,000 are living with advanced HF. These individuals report a high symptom burden including physical, emotional, and spiritual symptoms; all which contribute to an overall poor quality of life for both the individual and their families. Palliative care principles are recommended to meet the needs of individuals living with HF and their families and should be integrated throughout the illness trajectory, but low utilization of palliative care services in the HF population persists. There are several identified barriers that contribute to lack of palliative care services including the unpredictable illness trajectory, limited acknowledgement of HF terminality, and practitioner uncertainty when to initiate services. Purpose: The purpose of this investigation was to determine the utility of the predicted survival score from the Seattle Heart Failure Model (SHFM) as a guide for initiating palliative care referrals. Methods: Participants with a SHFM of < 2 year predicted survival (n=100) participated in a longitudinal study investigating the palliative care needs of persons living with advanced HF. Data collection occurred monthly for 2 years or until death of the participant. SHFM score was compared to date of death or end of data collection. Results: The mean predicted survival for the 100 participants at the time of enrollment from the SHFM was 1.8 years. The 51 participants who died during data collection, had a SHFM predicted survival mean of 1.7 years but a mean actual survival of 0.74 years. Of the 49 participants who were alive at the conclusion of data collection 43% (21/49) outlived their predicted survival. Twelve of the 21 who lived longer than their predicted survival had an intervention (transplant or mechanical circulatory support device). Conclusions: Even in the context of those living with advanced HF and a predicted survival of less than 2 years, the HF trajectory remains unpredictable at the end of life which makes the timing of palliative care referrals a challenge. The SHFM does not appear to be an effective screening tool for initiating palliative care services. Palliative care should be viewed as a philosophy of care initiated at the time of diagnosis with components of primary and specialized care.
278 276 Reengineering Heart Failure Patients’ Discharge Management Utilizing a Risk Stratification Model and Multidisciplinary Team Approach Reduces 30-Day All Cause Readmission. Patricia Ursomanno, Kris Natividad, Alexandra Spivak, Vera Dolgina, Aleksandar Adzic, Norbert Moskovits; Maimonides Medical Center, Brooklyn, NY
Proven Care: Quality Improvement in a Rural Tertiary Hospital Deepak Vedamurthy, Sanjay Doddamani, Haiyan Sun, Avery Schulze; Geisinger Medical Center, Danville, PA Introduction: It is clear that hospitals which employ Quality Improvement (QI) programs for heart failure have improved processes of care. However, the impact of these QI programs on outcomes measures are less well defined. We sought to evaluate
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Introduction: Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge at our institution is the large volume of hospitalized Heart Failure (HF) patients (5,000/year) with historically high 30-day readmission rates (23%). Hypothesis: Development of a designated multidisciplinary HF team (MD, NP, PharmD, and CM) that integrates a risk stratification model with a standardized comprehensive pre/post discharge management plan will decrease 30-day readmission rates. Methods: May 1 - July 31, 2017 was the implementation phase of the HF-Readmission Reduction Initiative (HF-RRI) Pilot Project. During this time, approval of administrative leadership, credentialing of HF-NP staff, unit based RN and case management (CM) orientation, and inclusion of a designated PharmD specializing in HF was completed. August 1, 2017 began the HF-RRI process which included generation of a daily patient list with Primary HF (ICD-10) and their associated HOSPITAL (risk for readmission) Score. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients with an intermediate to high risk HOSPITAL Score were flagged for further in-depth pre-discharge HF NP consult/ PharmD counsel, post discharge CHF Clinic 7-day appointment and weekly telephone assessments. Retrospective review of prospectively collected data was analyzed based on age, gender, length of stay (LOS), NYHA, HOSPITAL Score and 30-day readmission. Time periods included Pre-HF-RRI (November 1, 2016 -April 30, 2017); Implementation Phase (May1, 2017-July31, 2017); Post HFRRI (August 1, 2017-January 31, 2018). Results: We identified 242 Primary HF patients (116-Pre-HF-RRI and 126 Post HF-RRI). Continuous variables (age, LOS and risk score) and categorical variables (age75+, gender, NYHA, and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank sum and chi-square tests, respectively. The groups were comparable on age and gender. There were no differences in LOS, NYHA or HOSPITAL score. The 30day readmit rate was statistically significantly lower in the POST HF-RRI group compared to the PRE HF-RRI group, 10.3% (12/116) vs. 20.6% (26/126), respectively, p=0.0279. Conclusion: Our newly integrated multidisciplinary HF team approach that incorporates a risk for readmission HOSPITAL Score stratification can prevent avoidable 30-day readmissions.
275 “Teach a Man to Fish”: Clinician Perspectives on Primary Palliative Care in Heart Failure Zachariah P. Hoydich1, Matthew Harinstein1, Beth Rose2, Bruce Rollman1, Kathryn Berlacher1, Dio Kavalieratos1; 1University of Pittsburgh, Pittsburgh, PA; 2University of Pittsburgh Medical Center, Pittsburgh, PA Purpose: Heart failure (HF) is a common, debilitating disease that decreases both longevity and leads to decreased quality of life. Palliative care is a clinical subspecialty, and overall approach to care, that emphasizes alleviation of suffering through symptom management, psychosocial support, and assistance with complex treatment decision-making. Despite recommendations from major cardiology societies, specialty palliative care remains underutilized in HF. Accordingly major cardiology societies have called for clinicians without specialty palliative care training to deliver basic palliative competencies (i.e., “primary” palliative care), such as symptom management and goals-of-care elicitation. It is unclear what non-palliative care specialists caring for patients with HF view as barriers and facilitators to delivering primary palliative care. Methods: We conducted semi-structured phenomenological interviews with physicians, nurses, and physician assistants caring for patients with HF across the United States, recruited through a snowball convenience sample. Interview topics included: 1) a hypothetical treatment strategy for an advanced HF patient with significant unmet palliative needs; 2) knowledge and attitudes regarding the role of both primary and specialty palliative care in HF; and, 3) barriers and facilitators of primary palliative care integration in standard HF management. Two analysts independently coded data using template analysis, a hybrid inductive/deductive qualitative technique. Results: We interviewed 18 clinicians: 4 physicians and 2 advanced practice providers from primary care, cardiology, and palliative care specialties. 61% were female, 89% Caucasian, average age was 43, and the median years in practice, 12. We identified several barriers to primary palliative care integration including 1) structural and organizational barriers like time constraints; 2) attitudinal barriers, such as discomfort addressing goals-of-care; and 3) educational deficits including a perceived lack of training in primary palliative care skills (e.g., symptom management, difficult communication). Clinicians of all non-palliative specialties interviewed desired training in these skills. Conclusion: Many clinician-perceived barriers to the provision of primary palliative care in HF may be addressed through education regarding symptom management and advance care planning communication. Others, such as time constraints and organizational barriers, may be reduced through normalizing and integrating palliative care as a natural facet of standard HF management. While clinician respondents endorsed integrating primary palliative care into routine HF care, randomized trials are needed to establish the effectiveness of primary palliative care interventions, including HF primary palliative care curricula.
277 The use of the Seattle Heart Failure Model to Guide Palliative Care Referrals in Advanced Heart Failure Judith Hupcey1, Lisa Kitko2, Windy Alonso3, Elizabeth Thiede2; 1Penn State University, Hershey, PA; 2Penn State University, University Park, PA; 3University of Nebraska Medical Center, Omaha, NE Introduction: Of the over 6 million individuals living with heart failure (HF) approximately 5% or 300,000 are living with advanced HF. These individuals report a high symptom burden including physical, emotional, and spiritual symptoms; all which contribute to an overall poor quality of life for both the individual and their families. Palliative care principles are recommended to meet the needs of individuals living with HF and their families and should be integrated throughout the illness trajectory, but low utilization of palliative care services in the HF population persists. There are several identified barriers that contribute to lack of palliative care services including the unpredictable illness trajectory, limited acknowledgement of HF terminality, and practitioner uncertainty when to initiate services. Purpose: The purpose of this investigation was to determine the utility of the predicted survival score from the Seattle Heart Failure Model (SHFM) as a guide for initiating palliative care referrals. Methods: Participants with a SHFM of < 2 year predicted survival (n=100) participated in a longitudinal study investigating the palliative care needs of persons living with advanced HF. Data collection occurred monthly for 2 years or until death of the participant. SHFM score was compared to date of death or end of data collection. Results: The mean predicted survival for the 100 participants at the time of enrollment from the SHFM was 1.8 years. The 51 participants who died during data collection, had a SHFM predicted survival mean of 1.7 years but a mean actual survival of 0.74 years. Of the 49 participants who were alive at the conclusion of data collection 43% (21/49) outlived their predicted survival. Twelve of the 21 who lived longer than their predicted survival had an intervention (transplant or mechanical circulatory support device). Conclusions: Even in the context of those living with advanced HF and a predicted survival of less than 2 years, the HF trajectory remains unpredictable at the end of life which makes the timing of palliative care referrals a challenge. The SHFM does not appear to be an effective screening tool for initiating palliative care services. Palliative care should be viewed as a philosophy of care initiated at the time of diagnosis with components of primary and specialized care.
278 276 Reengineering Heart Failure Patients’ Discharge Management Utilizing a Risk Stratification Model and Multidisciplinary Team Approach Reduces 30-Day All Cause Readmission. Patricia Ursomanno, Kris Natividad, Alexandra Spivak, Vera Dolgina, Aleksandar Adzic, Norbert Moskovits; Maimonides Medical Center, Brooklyn, NY
Proven Care: Quality Improvement in a Rural Tertiary Hospital Deepak Vedamurthy, Sanjay Doddamani, Haiyan Sun, Avery Schulze; Geisinger Medical Center, Danville, PA Introduction: It is clear that hospitals which employ Quality Improvement (QI) programs for heart failure have improved processes of care. However, the impact of these QI programs on outcomes measures are less well defined. We sought to evaluate