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IHI Expedition: Effective Implementation of Heart Failure Core Processes Peg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director November 17, 2011 These presenters have nothing to disclose WebEx Quick Reference • Welcome to today’s session! Raise your hand • Please use Chat to “All Participants” for questions • For technology issues only, please Chat to “Host” • WebEx Technical Support: 866-569-3239 • Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text 2 When Chatting… Please send your message to All Participants 3 Chat Time! What is your goal for participating in this Expedition? 4 Join Passport to: • Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements. • Train your middle managers to effectively lead quality improvement initiatives. • Enhance your strategic planning with customized whole systems data and selected benchmarking information. . . . and much, much more for $5,000 per year! • • • Visit www.IHI.org/passport for details. To enroll, call 617-301-4800 or email [email protected]. What is an Expedition? ex•pe•di•tion (noun) 1. an excursion, journey, or voyage made for some specific purpose 2. the group of persons engaged in such an activity 3. promptness or speed in accomplishing something Christine McMullan Chris McMullan, MPA, is the Director of Continuous Quality Improvement at Stony Brook University Medical Center. She served as an adjunct faculty member at the Harriman Business School and School of Professional Development at Stony Brook University. She was Lead Faculty on the IHI Early Warning Systems: The Next Level of Rapid Response Expedition and a Faculty member on the IHI Sepsis Detection and Initial Management Expedition. She was a co-faculty member of the Hospital Association of New York State's 2007 learning collaborative to prevent ventilator associated pneumonia. Ms. McMullan has held a variety of managerial positions in quality improvement and human resources. Peg Bradke, RN, MA Peg M. Bradke, RN, MA, Director of Heart Care Services, St. Luke's Hospital, coordinates services for two intensive care units, two step-down telemetry units, the Cardiac Catheter Lab, Electrophysiology Lab, Diagnostic Cardiology, Interventional/Vascular Lab, and Cardiopulmonary Rehabilitation. In her 25year career, she has had various administrative roles in critical care areas. Ms. Bradke works with the Institute for Healthcare Improvement on the Transforming Care at the Bedside initiative and Transitions Home work. She is President-Elect of the Iowa Organization of Nurse Leaders. Where are you joining from? Ground Rules • We learn from one another – “All teach, all learn” • Why reinvent the wheel? - Steal shamelessly • This is a transparent learning environment • All ideas/feedback are welcome and encouraged! Schedule of Calls • November 17 12:00 – 1:30 PM ET Introduction, Objectives, Expedition Overview • December 1, 2011, 12 – 1 PM ET Importance of LVS assessment in the reliable recognition of HF • December 15, 2011, 12 – 1 PM ET Offering adult smoking cessation advice and counseling • January 5, 2012, 12 – 1 PM ET Benefits of providing ACE/ARBs at discharge for HF patients • January 19, 2012, 12 – 1 PM ET Anticoagulant at discharge for chronic atrial fibrillation • February 2, 2012, 12 – 1 PM ET Discharge instructions and dietary considerations Today’s Agenda • Expedition objectives and your survey responses • Medical management for heart failure • IHI’s Model for Improvement • Overview for increasing reliability with heart failure core processes • Homework for next session 12 Expedition Objectives • To provide hospitals with highly effective ideas and practices in improving reliability in the treatment of heart failure. The expedition will focus on key elements of care to ensure patients with heart failure have less severe symptoms, better quality of life, and fewer readmissions to the hospital. • Conduct left ventricular systolic (LVS) assessment • Provide adult smoking cessation advice and counseling • Provide ACE inhibitor or angiotensin receptor blockers (ARB) at discharge • Provide anticoagulant at discharge for chronic atrial fibrillation • Establish discharge instructions Survey Responses Director of Quality, Nurse Practitioner, Registered Nurse, Chart Abstractor and Clinical Nurse Specialist Survey Responses 15 Goal for participation • Learn from others • Collaborate with others in improving quality • To better understand core measure processes • Improve heart failure care • Prevent readmission How are you identifying patients? • • • • • Admitting diagnosis Concurrent review H&P medical diagnosis history Elevated BNP levels EMR triggers What are your barriers to reliability? • Physician and nurse lack of understanding of core measures • MD and RN collaboration on discharge instructions/medication reconciliation • Electronic health record – both pro and con • Inability to identify HF patients on admission 18 Last Quarter Composite Score William E. Lawson, M.D., FACCP, FACC, FSCAI Dr. William Lawson graduated from Rutgers Medical School in 1977. Dr. Lawson has been at SUNY, Stony Brook since 1980, where he is currently Professor of Medicine in the Division of Cardiology. At Stony Brook he has acted as Chief of Cardiology, Director of Echocardiography, Non-Invasive, Invasive, and Preventive Cardiology. He is currently Director of Cardiac Outcomes Research and Preventive Cardiology. Dr. Lawson is a practicing interventional cardiologist and Director of the Interventional Cardiology fellowship program at Stony Brook. Dr. Lawson is ABIM certified in Internal Medicine, Cardiovascular Disease, Interventional Cardiology, Advanced Heart Failure & Transplant Cardiology and is a Fellow of the ACC, ACCP, SCAI, ACA. He has broad expertise and interest in the field of cardiovascular disease and is actively involved in the teaching and mentoring of physicians and allied health care professionals at SUNY, Stony Brook. CONGESTIVE HEART FAILURE William E. Lawson, M.D., FACCP, FACC, FSCAI Stony Brook Hospital Heart Failure: A Growing Burden • Prevalence is increasing: – Aging populations, HBP, DM, MI survivors. – Overall rate is 3-20/1,000. – Rate over age 65 is 30-130/1,000. • One –year mortality rates are 35-45% in newly diagnosed cases. • Heart failure is the most frequent cause of hospitalization over age 65. Symptoms • Fatigue, easy tiring • Dyspnea, Dyspnea on exertion, Paroxysmal nocturnal dyspnea • Edema • Persistent cough/ wheezing • Palpitations, presyncope Congestive Heart Failure Cardiac cachexia Hepatomegaly JVD/ HJR Ascites New Classification of Heart Failure A B C D Stage Patient Description High risk of developing heart failure (HF) • • • • Asymptomatic LVD • Previous MI • LV systolic dysfunction • Asymptomatic valvular disease Symptomatic LVD • Known structural heart disease • Shortness of breath and fatigue • Reduced exercise tolerance Refractory end-stage HF • Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions) Hunt SA et al. J Am Coll Cardiol. 2001;38:2101-2113. Hypertension CAD Diabetes mellitus Family history of cardiomyopathy HF Risk Factor Treatment Goals Risk Factor Goal Hypertension Generally < 130/80 Diabetes See ADA guidelines1 Hyperlipidemia See NCEP guidelines2 Inactivity 20-30 min. aerobic 3-5 x wk. Obesity Weight reduction < 30 BMI Alcohol Men ≤ 2 drinks/day, women ≤ 1 Smoking Cessation Dietary Sodium Maximum 2-3 g/day 1Diabetes 2JAMA Adapted from: Care 2006; 29: S4-S42 2001; 285:2486-97 Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Treating Hypertension to Prevent HF Aggressive blood pressure control: Decreases risk of new HF by ~ 50% 56% in DM2 Lancet 1991;338:1281-5 (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:703-713 Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 80% After a 2 year visit to the US, Michelangelo’s David is returning to Italy Sponsored by Prevention—ACEI and Beta Blockers ACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with: Coronary artery disease Peripheral vascular disease Stroke Diabetes and another major risk factor Strength of Evidence = A ACE inhibitors and beta blockers are recommended for all patients with prior MI. Strength of Evidence = A Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Management of Patients with Known Atherosclerotic Disease But No HF Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest. 16 14 12 % MI, 10 Stroke, 8 CV Death 6 4 2 0 Ramipril 22% rel. risk red. p < .001 0 1 2 3 4 Years 15 EUROPA 12 NEJM 2000;342:145-53 (HOPE) Lancet 2003;362:782-8 (EUROPA) Placebo HOPE Placebo % MI, CV Death, 9 Cardiac 6 Arrest Perindopril 3 20% rel. risk red. p = .0003 0 0 1 2 3 Years 4 5 CAD; Leading Cause of Heart Failure • Post MI survivors – Magnitude of initial infarct, cumulative damage, adverse remodeling all play roles • Chronic ischemia and LV dysfunction – Prolonged ischemia causes hibernation, stunning – Shorter periods of ischemia result in reversible myocardial dysfunction Angioplasty Pre PCI Post PCI The Evolving Model of Heart Failure Treatment Cardiorenal Hemodynamic Neurohumoral Digitalis and diurtics improve cardiac and renal function Inotropes and vasodilators improve LV performance Modification of activation of adrenergic, RAAS systems Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%) SAVE Study 0.3 Mortality Rate All-cause mortality ↓19% Placebo 0.2 Captopril CV mortality ↓21% 0.1 HF development ↓37% Recurrent MI ↓25% 19% rel. risk reduction p = 0.019 0 0 0.5 1 1.5 2 2.5 3 3.5 4 Years Pfeffer et al. NEJM 1992;327:669-77 Added Value of BB Post-MI Beta blocker (carvedilol) benefit post-MI with LVEF ≤ 40%, receiving usual therapy [revascularization, anticoagulants, ASA, and ACEI]. Capricorn trial All-cause mortality reduced (HR = 0.077; p = 0.03) Cardiovascular mortality reduced (HR = 0.75; p = .024) Recurrent non-fatal MIs reduced (HR =.59; p = .014) Dargie HJ. Lancet 2001;357:1385-90 Causes of Dyspnea Therapy: ACE Inhibitors ACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers). Strength of Evidence = C ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Adapted from: Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HF SOLVD Prevention (Asymptomatic LVD) CONSENSUS (Severe Heart Failure) 20% death or HF hosp. 40% mortality at 6 mos. 29% death or new HF 31% mortality at 1 year 27% mortality at end of study SOLVD Treatment (Chronic Heart Failure) 16% mortality No difference in incidence of sudden cardiac death SOLVD Investigators. N Engl J Med 1992;327:685-91 SOLVD Investigators. N Engl J Med 1991;325:293-302 CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35 Therapy: Beta Blockers Beta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days Improvement 100% 91% 73% 75% Patients 18% P <.0001 50% 25% 0% Carvedilol Predischarge Initiation (n=185) Physician Discretion Postdischarge Initiation* (n=178) Gattis WA et al. JACC 2004;43:1534-41 Therapy: Angiotensin Receptor Blockers ARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency. Strength of Evidence = A Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-Alternative Val-HeFT CV Death or HF Hosp % Survival % CHARM-Alternative 50 100 Valsartan 90 80 Placebo 70 Placebo 40 30 Candesartan 20 10 60 p = 0.017 HR 0.77, p = 0.0004 0 50 0 3 6 9 12 15 18 21 24 27 0 9 Months 18 27 Months Maggioni AP et al. JACC 2002;40:1422-4 Granger CB et al. Lancet 2003;362:772-6 36 Therapy: Aldosterone Antagonists An aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have: NYHA class III or IV HF from reduced LVEF (≤ 35%) One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker. Strength of Evidence = A Adapted from: Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Aldosterone Antagonists in HF EPHESUS (Post-MI) Probability of Survival RALES (Advanced HF) 1.00 1.00 0.90 0.90 0.80 Spironolactone 0.70 Eplerenone 0.80 Placebo 0.70 0.60 0.60 Placebo 0.50 0.50 RR = 0.70 P < 0.001 0.40 RR = 0.85 P < 0.008 0.40 0 3 6 9 12 15 18 21 24 27 30 33 36 0 3 6 9 12 15 18 21 24 27 30 33 36 Months Pitt B. N Engl J Med 1999;341:709-17 Pitt B. N Engl J Med 2003;348:1309-21 Therapy: Hydralazine and Oral Nitrates A combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF: NYHA III or IV HF Strength of Evidence = A NYHA II HF Strength of Evidence = B Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. A-HeFT All-Cause Mortality 43% Decrease in Mortality 100 Survival % Fixed Dose ISDN/HDZN 95 90 Placebo P = 0.01 85 0 100 200 Days Since Baseline Visit 300 400 500 600 Taylor AL et al. N Engl J Med 2004;351:2049-57 Therapy: Diuretics Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by: Congestive symptoms Signs of elevated filling pressures Strength of Evidence = A Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF. Strength of Evidence = B Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Treatment by Heart Failure Stage Stage A Stage B Treat HBP Stop smoking Treat lipids Exercise No ETOH No Drugs ACEI in DM, HBP, Vascular Disease All Stage A measures ACEI in post MI, reduced LVEF BB in post MI, reduced LVEF Stage C Stage D All Stage A All Stage A, measures B,C measures ACEI LVAD Diuretics Ht Transplant BB Continuous Digitalis IV inotropes Spironolactone in Class III,IV Device Therapy: Prophylactic ICD Placement Prophylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Strength of Evidence = A Non-ischemic etiology Strength of Evidence = B In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered. Strength of Evidence = B Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy. Strength of Evidence = C Adapted from: Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%) Probability of Survival 1.0 .9 .8 Defibrillator .7 Conventional Therapy .6 0 0 Number at Risk Defibrillator Conventional 1 2 3 4 110 (.78) 65 (.69) 9 3 Year 742 490 503 (.91) 329 (.90) 274 (.84) 170 (.78) Moss AJ et al. N Engl J Med 2002;346:877-83 Resynchronization Two leads allow pacing of the right atrium and ventricle. The third lead is advanced through the coronary sinus into a venous branch along the lateral wall of the left ventricle, allowing early activation of the left ventricle. Device Therapy: Biventricular Pacing Biventricular pacing therapy is recommended for patients with all of the following: Sinus rhythm A widened QRS interval (≥120 ms) Severe LV systolic dysfunction (LVEF < 35%) Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy. Strength of Evidence = A Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. CRT Improves Quality of Life and NYHA Functional Class Average Change in Score (MLWHF) NYHA: Proportion Improving by 1 or More Class 0 80 -5 * * * 60 -10 (%) -15 * * * 40 * Control EI CD 20 0 MI RA CL D AK C CO NT SR ST IC MU MI RA CL E -20 CRT MIRACLE *P<.05 CONTAK CD Control MIRACLE ICD CRT Abraham WT et al. Circulation 2003;108:2596-603 CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANION Primary End Point: All-Cause Mortality Death or Hospitalization Due to HF Risk of all-cause mortality reduced by 19% in group with CRT and ICD (p =.014) Risk of death or hospitalization from HF reduced by 34% in ICD group and by 40% in ICD-CRT group (p < .001) Bristow MR et al. N Engl J Med 2004;350:2140-50 Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF % Event-Free Survival 100 75 CRT 50 Medical Therapy 25 HR = 0.64 (95% CI = .48-.85) p = .0019 0 Number at risk CRT Medical Therapy 0 409 404 500 376 365 351 321 Days 213 192 1,000 89 71 1,500 8 5 Cleland JG et al. N Engl J Med 2005;352:1539-49 Treatment Options: Acute Decompensated HF Fluid and sodium restriction Diuretics, especially loop diuretics Ultrafiltration/renal replacement therapy (in selected patients only) Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide) Inotropes (milrinone or dobutamine) Lindenfeld J, et al. HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194. Clinical Presentation of Acute Decompensated Heart Failure Clincal Evaluation of Acute Decompensated Heart Failure Impact of Education on Compliance Nonadherence rate when patients . . . Recall MD advice Don’t recall advice Medications 8.7% 66.7% Diet 23.6% 55.8% Activity 76.4% 84.5% Smoking 60.0% 90.4% Alcohol 60.0% 81.8% Kravitz et al. Arch Int Med 1993;153:1869-78 Evidence-Based Treatment Across the Continuum of Systolic LVD and HF Control Volume Diuretics Improve Clinical Outcomes Aldosterone ACEI -Blocker Antagonist or ARB or ARB ±CRT & ICD Hydralazine/Isosorbide dinitrate Treat Residual Symptoms Digoxin ? The Future: Angiogenesis/ Myogenesis via Cell Transplants Questions? Raise your hand Use the Chat 62 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Act Study Aim of Improvement Measurement of Improvement Developing a Change Plan Do Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996. Act • Decide changes to make •Arrange next cycle Study • Complete data analysis •Compare to predictions •Summarize learning Plan • Compose aim •Pose questions/predictions •Create action plan to carry out cycle (who, what, when, where) •Plan for data collection Do • Carry out the test and collect data •Document what occurred •Begin analysis of data Principles & Guidelines for Testing • A test of change should answer a specific question • A test of change requires a theory and prediction • Test on a small scale • Collect data over time • Build knowledge sequentially with multiple PDSA cycles for each change idea • Include a wide range of conditions in the sequence of tests Repeated Use of the PDSA Cycle Sequential building of knowledge under a wide range of conditions Changes That Result in Improvement A P S D Spread Implementation of Change Hunches Theories Ideas Wide-Scale Tests of Change A P S D Very Small Scale Test Follow-up Tests Aim: Implement Rapid Response Team on nonICU unit Improved Communication A P S D A P S D Cycle 6: Expand rounds to one unit for one shift seven days a week Cycle 5: Have Nurse Practitioner respond to calls in addition to RT and RN Cycle 4: Expand coverage of RRT on unit to one unit for one shift for five days Cycle 3: Have Respiratory Therapist attend rapid response calls with ICU Nurse Cycle 2: Repeat cycle 1 for three days Cycle 1: ICU nurse responds to rapid response team calls on one unit, one shift for one day Questions? Raise your hand Use the Chat 68 IHI Heart Failure Expedition IHI Expedition 2011 Peg M. Bradke, RN, MA St. Luke’s Hospital, Cedar Rapids, Iowa Heart Failure Core Measures • • • • HF1 – Discharge Instructions HF 2 – Evaluation of LVS Function HF 3 – AEI or ARB for LVSD HF 4 – Adult Smoking Cessation Advice/Counseling 70 What are the drivers? • Doing the Right thing with Evidenced Based Care for our Patients • Meeting requirements for Valued Based Purchasing • Marketing –Consumer Access to Hospital Compare.gov • Reducing Our Potential Avoidable Readmissions Doing the Right thing • The right care for every patient, every time • Is any defect acceptable ─ To us as a health care system? ─ To you as a health care professional? ─ To anyone expecting the care we would want our loved ones to receive? ─ Which would you be okay with your loved not getting? Legislative Requirements for VBP Multiple Requirements • Legislation requires that the FY 2013 Hospital VBP program apply to payments for discharge occurring on or after Oct. 2012 • Hospital VBP measures must be included on Hospital Compare website • Under proposal, measures could be added to Hospital VBP if measures have been displayed on Hospital Compare for one year HQA Recent Report for HF 10%of all Hospital National Performance Submitting equal to or better than 100% HF 1-discharge HF 2- LV function HF 3- ACE/ARB HF 4- Smoking Cessation 100% 100% 100% 100% 90% 98% 95% 97% “The Billion Dollar U-Turn” • 17.6% of all Medicare admissions are readmissions within 30 days ─ Accounting for $15 B in spending • Not all re-hospitalizations are avoidable, but many are ─ ─ ─ ─ ─ 13.3% of all Medicare admissions; 76% potentially avoidable Accounts for $12B in Medicare spending Heart Failure, Pneumonia, COPD, Acute MI lead the medical conditions CABG, PTCA, other vascular procedures lead the surgical conditions Disparities exist along racial and “burden of illness” lines • There is wide intra-state and inter-state variation ─ Medicare 30-day readmission rate varies 13-24% by state Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008 MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007 Commonwealth Fund State Scorecard on Health System Performance. June 2007 STAAR Initiative: Two Concurrent Strategies • Provide technical assistance to front-line teams of providers working to improve the transition out of the hospital and into the next care setting • • • Actively engage hospitals and their community partners in co-designing processes to improve transitions Provide coaching by content experts and facilitate collaborative learning with the goals of creating exemplary cross continuum models in each state and identifying highleverage changes in each care setting Develop quality improvement expertise and content experts to mentor others • Create and support state-based, multi-stakeholder initiatives to concurrently examine and address the systemic barriers to improving care transitions, care coordination over time. • • • State leadership, steering committees, key allies, aligning initiatives Technical assistance to “staff” challenges in framing the issue, designing strategy, scanning for developments in best practice/policy Specific focus areas: understanding the financial impact of success, aligning payment to support high leverage interventions, developing state rehospitalization data reports IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Post-Acute Care Activated Transition from Hospital to Home • MD Follow-up Visit Alternative or Supplemental Care for High-Risk Patients * • Hospice/Palliative Care • Home Health Care • Transitional Care • Enhanced (as needed) Models Assessment • Social Services (as • Intensive Care • Teaching and needed) Management (e.g. Learning Patient-Centered or • Real-time Handover Medical Homes, HF Communications Clinics, Evercare) • Skilled Nursing • Follow-up Care Facility Services * Additional Costs Arranged for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations Creating an Ideal Transition Home I. B. C. D. Perform Enhanced Admission Assessment of Post-Hospital Needs Involve the patient, family caregivers and community providers as full partners in completing a needs assessment of the patient home going needs Reconcile medications C. Identify the patient’s initial risk of readmission Create a customized discharge plan based on the assessment. II. A. B. C. D. Provide Effective Teaching and Facilitate Enhanced Learning Involve all learner in patient education Redesign patient education process Redesign patient teaching print materials Use Teachback regularly throughout the hospital stay A. III. Ensure Post-Hospital Care Follow-Up A. Reassess the patient’s medical and social risk for readmission. B. Prior to discharge: • Schedule timely follow-up care and • Initiate clinical and social services summarized from the assessment of post-hospital needs. IV. A. B. C. Provide Real-Time Handover Communication Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list. Provide customized, real-time critical information to next clinical care provider(s). For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care. Analysis of Results-to-Date • Reducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time • Improving transitions in care requires co-design of transitional care processes among “senders and receivers” • Providing intensive care management services for targeted high risk patients is critical • Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months Other Resources • BOOST ─Toolkit –Medication Reconciliation, Treatment plan, discharge summary communication • Hospital to Home H2H (ACC/IHI) ─Virtual Learning Community and H2H website • Project RED ─Reconciling the discharge plan with national guidelines and critical pathways when relevant – CMS discharge list Building Reliability • Need Reliability of the Evidenced Based Core measures to build on the continuum of care after discharge • Core Measures work in tandem with Readmission Effort • First step identifying the Core Measure Patients Who identifies the HF Core Measure Patients • Frontline Staff vs. dedicated individual Frontline staff needs to understand the measures and the context of the work • All departments must take ownership to manage the process • Role of Nursing Unit Leadership and Senior Leadership How do you identify the HF Core Measure Patient? BNP: ß-type Natriuretic Peptide ─ Hormone released into the blood in response to increased heart pressure or overload ─ Circulating BNP has an inverse relationship to degree of cardiac dysfunction (the higher the BNP, the lower the ejection-fraction and the higher New York Heart Association Level) IV Lasix/Diuretic Report Follow Up in EMR Verify the patient has HF through chart review and daily rounds • • • Patient has symptoms of HF Physician notes that patient exhibits symptoms of HF Note if patient has previous history of HF Is Your Approach “Real Time” • Reviewing Concurrently with concurrent chart abstraction ─ Literature reports the results of core measures improved significantly. These methods prove to be efficient and cost effective as les time was required when compared to retrospective chart review and more current data were available to anaylze and act upon. ─ Advantages include just in time one to one education of staff, optimizing evidenced based patient care opportunities and documentation, and responding to staff questions. Documentation • Documentation is a key driver ─Accurate and complete to meet measure definitions ─Impact on coding ─Patient Safety ─Maximize Reimbursements Results Retrospective of Chart Review Six patients did not have proper discharge instructions: • Two patients had cancer – documentation of chemo-induced heart failure • One patient with admitting diagnosis of allergic reaction • One patient ICD implant • Remaining two were heart failure diagnoses that were missed Core Measure Discharge Tools or Checklists • Are you using a Discharge Checklist to assess compliance during the hospitalization and then at the time of discharge with national guidelines for care of HF patient Please share you tools/checklist or processes over the time of this expeditions. HF – 1 Discharge Instruction Numerator: Heart Failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: 1. Activity level 2. Diet 3. Discharge Medications 4. Follow up appointment 5. Weight Monitoring 6. What to do if symptoms worsen Denominator: Heart failure patients discharged home 91 HF Discharge Instructions • Use pre-printed heart failure discharge instructions on the following patients: newly diagnosed or history of heart failure patients that we are currently treating for HF; history of ischemic cardiomyopathy or LVEF <40; patients currently hospitalized to have Bi-V or ICD implant who have a history of CHF or LVEF <40%. PATIENT EDUCATION • YOU ARE THE PATIENT’S LIFELINE FOR INFORMATION! • Give in small doses • Use their terms • Be empathetic but emphatic! • Ask specific questions to determine their knowledge level (how much sodium/how much weight to report/when to weigh, etc.) Medication Reconciliation ♥ Home Medication List ♥ Hospital Medication List ♥ Discharge Instructions ♥ Physician’s Discharge Summary ALL MUST MATCH EXACTLY!! Many errors around lack of medication reconciliation at discharge Medication Reconciliation cont. Includes ♥ All prescribed medications ♥ All over the counter medications ♥ All PRN medications ♥ Medication name, dosage and route Same rules apply for Long term or skilled care facilities Medication Reconciliation cont. • What is your check process for your providers and staff? Do you do a discharge time out? Do you do a double check by two independent reviewers? Is a Pharmacist involved? • How do you assure all medications are addressed? • How do you assure required discharged medications are addressed? HF 2- Evaluation of LVS Function • Numerator: Heart failure patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. • Denominator: Heart failure patients 97 EF • Amount of blood pumped out of the heart with each contraction • Normal = 50 – 70% • Abnormal in CMS world = <40% HF 3 – ACEI or ARB for LVSD • Numerator: Heart Failure patients who are prescribed an ACEI or ARB at hospital discharge • Denominator: Heart failure patients with LVSD 99 Contraindications CMS updates the measures twice a year – the contraindications frequently are areas that are changed. Don’t worry about specific contraindications. Just encourage the Providers to document any contraindications (i.e. CHF & Acute Beta Blockers or Coumadin and Acute ASA) HF 4 – Adult Smoking Cessation Advice/Counseling • Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay • Denominator: Heart failure patients with a history of smoking cigarettes any time during the year prior to hospital arrival 101 SMOKING ALL PATIENTS regardless of diagnosis, need documentation of smoking education (cessation education, stay quit or second hand smoke exposure). ♥ If unable to give this to the patient, it can be given to the family. ♥ If unable to give education at the time the initial nursing history/assessment is completed and documented, smoking education cessation should be documented when the patient is able to receive the information HF BEST PRACTICE • LVEF Assessment – preferably within the past two years • Smoking cessation education for current smokers and those who have smoked in the past 12 months • ACE Inhibitor or ARB prescribed at discharge for patients with LVEF of less than 40% (if ACE or ARB is not used the physician needs to document the reason for both) • Preprinted CHF Discharge Instructions Utilized – to cover key CHF information including weight monitoring, medications, diet, what to do if symptoms worsen, activity and follow-up Make your process sustainable over time • Continually manage the process using the PDSA cycle • Keep your eye focused on enhancing the process rather than blaming someone or some group for failure • Key to work: culture change, communication and teamwork Let’s use this expedition to share our best practices and learn from each other. Homework for Next Call • What has been your experience in concurrent data abstraction for core measures as opposed to retrospective? ─Do you have results that demonstrate improved efficiency and/or results for a given method? ─Be prepared to discuss your findings for advantages/or disadvantages for the method you are utilizing. Expedition Communications • If you would like additional people to receive session notifications please send their email addresses to [email protected]. • We have set up a listserv for the Expedition to enable you to share your progress. To use the listserv, address an email to [email protected]. Next Session December 1, 2011, 12 – 1 PM ET Importance of LVS assessment in the reliable recognition of HF 107