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Development of a Heart Failure Program to Decrease Readmissions and Meet the Requirements
for Advanced Heart Failure Certification
Laura Grieve ANP-BC, CCRN, AAHFN-BC, Brooke McDuffie ACP-BC
and John Baker
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Development of a Heart Failure Program to Decrease Readmissions and Meet the Requirements
for Advanced Heart Failure Certification
Abstract
This article describes a comprehensive Heart Failure (HF) program designed to meet
specific institutional goals. The Personnel involved in the HF Program, the Systems employed to
provide the care for the target population, and a summary of the Heart Failure Care Pathway
are described in detail. Common difficulties encountered when establishing a HF Program were
examined and the mechanisms employed to overcome these difficulties were delineated. An
example of ongoing Performance Improvement efforts was also included.
Keywords
Heart Failure Program, Readmissions Reduction, Transitional Care
Overview
Heart Failure (HF) is one of leading causes of hospitalization and readmissions in the
United States. The American Heart Association (AHA) estimated that in 2010, 6.6 million adults
> 18 years of age had HF. By 2030 this number will have climbed to 9.6 million, an increase of
25%. HF is the number one cause of hospitalizations for people over the age of 65. One in nine
deaths has HF mentioned on the death certificate. The cost of caring for the increasing number
of patients experiencing HF is staggering and threatens to overwhelm an already overburdened
health care system (Roger, 2012). This has resulted in the development of many new programs
and initiatives designed to improve care, decrease morbidity and mortality, and decrease cost
for patients experiencing HF.
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The purpose of this article is to describe a comprehensive hospital based Heart Failure
Program (HF Program) developed at a 528 bed, nonprofit hospital in the Northeast Florida,
Southeast Georgia area. This program was developed in response to the institution’s need to
decrease the readmission rate for HF patients and to meet the requirements for Joint
Commission Advanced HF Certification. This HF Program serves an average of 950 patients per
year. The average age of the HF population is 71.79 years with 52.8% being male and 47.2%
being female.
The number of patients experiencing Heart Failure with reduced Ejection
Fraction (HFrEF) is 64.3% and 35.7% are experiencing Heart Failure with preserved Ejection
Fraction. (HFpEF). The average number of co morbidities is 6.7. Sharing this ongoing experience
may assist other institutions attempting to develop HF Programs to meet similar needs.
Getting Started
Vital to the success of any program is full support of the hospital’s administration,
clearly defined goals, and a practice framework. Administration made the care of HF patients a
hospital wide priority and pledged to provide the support and resources necessary to develop a
comprehensive HF program. This allowed for the formation of a multidisciplinary HF Task Force,
the initiation of daily rounding, and facilitated the removal of general cultural and operational
barriers. Initially the program resources consisted of a Nurse Practitioner (NP) and a
Cardiologist.
It was soon expanded to include a second NP and two Transitional Care
Coordinators (TCCs).
The goals for our HF Program were to: 1) Create a program that would decrease
the readmission rate for HF patients at our institution and 2) Create a program that would allow
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us to meet the requirements for and a obtain Joint Commission Advanced HF Certification. The
program practice framework was the ACCF/AHA Guideline for the Management of Heart Failure
(Yancy, 2013), the Advanced Disease-Specific Care Certification Requirements for Heart Failure
(The Joint Commission.2014, March) and the AHA Get with the Guideline-Heart Failure (GWTG)
(American Heart Association, 2014).
Identifying the Population
The target population for the HF Program is patients discharged with a primary
discharge diagnosis of HF (ICD-9-CM category 428). One of the foremost hurdles we faced in
our program was how to PROSPECTIVELY identify the target population. It is essential to
identify these patients at admission in order to initiate the HF Standing orders and facilitate the
provision of Guideline Directed Medical Therapy (GDMT).
Initial patient identification was attempted by reviewing the daily list of hospital
admissions and compiling a list of patients with an admitting diagnosis of HF. It soon became
apparent that this method was inadequate. Many actual HF patients were being missed and
many who were admitted with “HF” were not really experiencing HF.
Through trial and error the following method was devised to identify the target
population. The NP obtains a daily list of patients with an elevated BNP within the last 24 hours.
The names of patients with an admitting diagnosis of HF, a Cardiac Rehab HF Education
consultation, or who appear on the daily HF Core Measure list are then added to this list. The
charts of the listed patients are systematically reviewed (Diagram 1) and a determination of the
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patient’s inclusion or exclusion from the target population is made. These patients comprise the
Daily Census List.
Using this method we have been able to identify 96.1% of the patients at our institution
who were ultimately discharged with a primary discharge diagnosis of HF (ICD-9-CM category
428). The charts of patients who were “missed” are reviewed monthly in order to determine
why they were missed. The majority of patients “missed” were found to have been admitted
and discharged over a weekend or they did not meet HF inclusion criteria when initially
reviewed. The charts of the patients in the latter group are reviewed by a Cardiologist and the
Coding Manager to clarify the patient’s actual HF status.
Using this identification method has resulted in a significant drop in the number of
patients discharged with a diagnosis of HF, where the monthly trend for discharge volume
coded under ICD9-CM primary diagnosis of 428.xx has declined 80.4% since January 2010 as
seen in the chart below.
Such a decline is, statistically, one of the starkest developments of the entire program.
At its core, we learned that highly accurate identification of the HF population requires a close
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working relationship with the Systems Reimbursement/Coding and the Clinical Documentation
Departments. These departments have a significant impact on the size of the target population
and the accuracy with which they are identified.
Initial concerns centered on a non-trivial volume of patients discharged with a final
diagnosis of HF whom we had not identified prospectively and followed during their
hospitalization. Upon review of the outlier charts, we found that, frequently, the basic cause of
admission was due to problems other than HF. Examples include patients experiencing Atrial
Fibrillation with rapid ventricular response or Coronary Artery Disease requiring intervention,
patients with End Stage Renal Disease with resulting volume overload, or patients experiencing
pneumonia or an exacerbation of Chronic Obstructive Pulmonary Disease.
The charts of patients currently hospitalized with a possible discharge diagnosis of HF
not included on the Daily Census List are also reviewed. We then contacted the patient’s
admitting physician to clarify the patient’s HF status. The heightened interdisciplinary dialogue
led us to both include patients who would have previously been missed and---far more
frequently---to eliminate patients who were not truly experiencing a hospitalization primarily
due to HF.
Providing Comprehensive Care
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The ACCF/AHA Guideline for the Management of Heart Failure the Advanced DiseaseSpecific Care Certification Requirements for Heart Failure, and Get with the Guideline-Heart
Failure provided the means to identify the services needed to ensure that the HF patients were
receiving Guideline Directed Medical Therapy (GDMT) as well as appropriate transitional and
post discharge care.
Personnel (Diagram 2)
The HF program is implemented by a multidisciplinary team and is managed by two NPs.
The NPs are nationally certified in HF and have extensive experience caring for patients with HF
in the inpatient and outpatient setting. They coordinate the care of the HF patients during
hospitalization, through transition and for one month post discharge. The NPs, work closely
with the admitting physician and the consultants, develop and implement a plan of care based
on the ACC/AHA Guidelines. They coordinate the efforts of all the disciplines involved in the
patient’s care and adjust the plan of care as needed.
The TCCs are Registered Nurses (RNs) with clinical and care management backgrounds.
They assist the NPs in coordinating the care of the patients in the HF Program. The TCCs meet
with the HF patient throughout their hospitalization. They provide HF education, assist the
patient in obtaining needed equipment, services, medications, or transportation, and provide a
< 7 day follow up with a health care provider prior to discharge. During transition they insure
that the patient’s hospital records are sent to the appropriate provider, they contact the
patient as specified in the Post Discharge Call Back Format (defined in Systems) and serve as a
resource person and problem solver.
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There are two designated HF units in the hospital. The majority of the HF patients are
placed on these units. The nursing staff on these units receives extra training regarding the
care of HF patients. They complete a required HF Module yearly and participate daily in
Rounding for Results (RFR). They have the day to day responsibility for implementing the plan
of care and assessing its effectiveness. The nursing staff provides HF teaching for patients and
families and they reinforce the teaching provided by all the other disciplines.
Rehabilitative Services (Physical and Occupational Therapy) evaluates each HF patient
and make a determination of the patient’s current level of functioning, what needs to be done
to improve their functional abilities, and what services and equipment they will need at
discharge. They also administer the Six Minute Walk Test (American Thoracic Society, 2002)
and the Minnesota Living with Heart Failure Questionnaire (Rector, 1992).
Pharmacy Services evaluates the patient’s HF medication regimen throughout the
hospitalization providing recommendations re: optimization and streamlining patient’s
medication regimen. At the time of discharge they review the Medication Reconciliation
Record given to the patient, and provide additional HF medication education.
Care Management evaluates each HF patient to identify any physical, psychosocial, or
financial barriers that may be present. They then arrange the services necessary to overcome
these barriers.
Home Health Services are recommended for all eligible HF patients.
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Representatives from the major Home Health agencies serving our institution participate in RFR
and are in close contact with the NPs and TCCs should problems arise after the patient is
discharged.
Dietary Services evaluates the HF patient’s nutritional status and provides education
regarding low sodium diet or any other indicated dietary requirements.
Cardiac Rehabilitation provides each HF patient with comprehensive HF education and
screens the patient for eligibility for Cardiac Rehabilitation Services post discharge. They also
coordinate HF University (defined under Systems).
The Clinical Statistician developed and maintains an in-house HF Registry. The HF
Registry provides a consolidated data base where all the information necessary to meet the
requirements for the Readmission Reduction Initiative and Advanced HF Certification. The HF
Registry is the repository for the data used to characterize our specific HF population and
provides a means to regularly assess the effectiveness of the program and make program
adjustments as needed.
Systems
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Standing Order Sets- The HF Program has two Standing Order Sets. 1)HF Standing Orders
include all appropriate prerequisite medications and testing as well as consults to all disciplines
involved in the care of HF patients. The HF Standing orders are initiated by the admitting
physician. If they have not been initiated at admission they are initiated by the NP. The
compliance rate for initiation of HF Standing Orders at admission increased 236% from August
2013 to April 2014. This is primarily due to the HF Standing Order Set being embedded in the
computerized telemetry admission order set. 2) Health Home Health Standing Orders are
initiated by the Care Manager at the time of discharge. They outline the HH services required
for all patients discharged with a primary diagnosis of HF.
Standardized Work Sheets and Selected Instruments- the HF Program has a standard
format for each part of the HF Program Pathway. This includes a Daily Census Sheet, a RFR
Sheet, the NP Consult Sheet, the TCC Consult Sheet, the HF Clinic Progress Note, and the
Patient Medication Log. Specific validated instruments are employed to classify and evaluate
the HF patients. These include the Yale Readmission Risk Calculator (Krumholz, 2008), the Six
Minute Walk Test, the Minnesota Living with Heart Failure Questionnaire, and the NYHA
Classification System and the ACC/AHA Stages of HF (Yancy, 2013 p. 15).
Rounding for Results (RFR)- RFR is the process whereby a multidisciplinary team meets
daily to review the patient’s current treatment plan, correct any deficits or make changes as
needed, evaluate the patient’s progress, coordinate the efforts of all the disciplines, identify
any barriers, and provide an increased team understanding of the patient’s overall plan of care.
RFR includes the NPs, the TCCs, the Assistant Nurse Manager, the nurses caring for the patients,
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Rehabilitative Service, Dietary Service, Care Management, Home Health, and Pharmacy
Services. The plan of care developed during RFR is shared with the patient by the nurse caring
for the patient or the appropriate team member
Post Discharge Call Back Format- The HF Post Discharge Call Back Format is as follows:
the TCCs call each HF patient 24-48 hours post discharge, the day before and the day after their
follow up appointment, 2 weeks post discharge and as needed. Each HF patient also receives a
phone call at three weeks post discharge, 4 weeks post discharge and as needed from the
Contracted Call Back Service.
Less than 7 Day Follow up- The TCCs provide all HF patients with a < 7 day follow up
appointment in HF Clinic or with their Cardiologist prior to discharge.
HF Clinic- Initially we had difficulty arranging the < 7day follow up with a Health Care
Provider required by the Advanced Disease-Specific Care Certification Requirements for Heart
Failure. Health Care Providers could not provide appointment times within the prescribed time
frame, patients were not established with a provider, or the patient was uninsured or had
limited resources. To address these issues a NP run HF Clinic was established. The HF clinic also
allowed us to quickly see patients who are having problems. Because these patients were seen
quickly and appropriate interventions instituted, we have been able to decrease the number of
unnecessary Emergency Department visits and repeat hospitalizations in our target population.
To this end, a key internal metric tracked is the 3-month moving average for 30-day inpatient
HF readmissions; that figure has declined 26.4% since the first quarter of 2010, as seen in the
chart below:
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Michael McIvor’s Establishing a Heart Failure Program was used as a guide to develop
the HF Clinic. Currently HF Clinic is two afternoons per week. Each HF Clinic visit is scheduled
for 30 minutes to allow the time necessary to deal with these complex patients. At each visit
the HF education areas previously provided during their hospitalization) are reviewed (Yancy,
2013 p.15). The patient’s current HF regimen is reviewed and optimized. The plan of care is
discussed with the patient and they are provided with a printed Patient Medication Log.
Financial constraints play a large part in compliance for a significant portion of our
patient population. Resources have been allotted to provide the HF patients with many of the
necessary services free of charge. This includes HF Clinic appointments as needed for 30 days, a
one month supply of HF medications, a scale, pertinent labs, transportation to and from the
follow up visits, and HF University. Many patients also lack the resources to continue with
appropriate follow up after their 30 days with the HF Clinic is complete. The TCCs and the
financial advisors assist these patients in applying to the various programs available to them in
order to meet their long term health needs.
HF Readmission Review Board-This board consists of the NPs, the TCCs, two
Cardiologists, Nephrologist, Hospitalist, the Coding Manager, and HH representatives.
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The
Board meets weekly to review the charts of readmitted patients from the previous week and
the patient’s admission is deemed preventable or not preventable. If the admission is deemed
preventable, a plan to prevent future readmission is devised. This plan is shared with the
involved provider.
Heart Failure University- HF University is a series of eight classes pertaining to
understanding and living with HF available to all HF patients and their families. Each class is one
didactic hour and one hour of supervised exercise. The classes are taught by the members of
the multidisciplinary team and occur on a regular rotating basis. When the patient has
completed all eight classes, those who qualify are encouraged to transition into Cardiac
Rehabilitation.
HF Registry- As the HF program was starting, our facility was utilizing a paper-based
medical record. In order to avoid the confusion and fragmentation of having multiple
spreadsheets managed by the various associates tasked with HF duties, the clinical statistician
constructed a HF Registry based on the Oracle Corporation’s Oracle Apex freeware product.
This web-based tool enabled simple but effective deployment of the HF Registry app to our
intranet.
Performance Improvement Forum- The NPs meet monthly to discuss what is working
and what isn’t, to reassess and revise the Standardized Work Sheets and Selected Instruments,
and to update the HF Program to include new requirements and ideas. An example of how the
Performance Improvement Forum has impacted the program follows.
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An evaluation of the effectiveness of the Yale Readmission Risk Calculator as an accurate
predictor of readmission in our program. Pursuit of the Advanced Certification for Heart Failure
required selection of a readmission risk assessment tool. For this purpose, the Yale risk scoring
methodology was selected. Readmission risk scoring using Yale began in earnest in January
2013. Scoring was done by nurse practitioners, who keyed risk elements into the Yale site
(www.readmissionscore.org/heart_failure.php), and recorded the resulting score in the local HF
Registry.
By the mid-spring of 2014, nearly 600 patients age 65+ had been scored for readmission
risk in this manner. At that time, a review of the efficacy of the Yale score was requested by a
nurse practitioner. Using the statistical software platform R, the team statistician ran logistic
regression on actual incidence of 30-day inpatient readmission vs. the Yale score. The focus
was limited to patients age 65 and older who were discharged alive, with a primary diagnosis
substantially related to heart failure. The result: the p-value for the Yale score and our actual
30-day inpatient readmission (to the same facility) exceeded 0.50. This indicates the Yale HF
readmission risk assessor had essentially no predictive power for readmissions, among the
patients actually scored.
The chart below displays the predicted chance of readmission by score range along with
the actual readmission rate for those categories, as determined by the Yale score:
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After statististical investigation, a better risk predictor for our patients turned out to be:
r = 8% + (1% x HF LOS) + (5% x Recent IP/Obs Stays)
Where r = the predicted chance of 30-day inpatient readmission, HF LOS = length of
hospitalization in the index HF hospitalization, and Recent IP/Obs Stays = the number of
inpatient or observation stays at our facility, for any reason, in the 180 days prior to the HF
hospitalization. The 8% is a global constant applied to all cases.
Under this model, a patient discharged with HF after a 6-day stay, and having one prior
hospitalization in the past 180 days would have a predicted readmission risk as follows…
r = 8% + (1% x 6 days) + (5% x 1) … or, 8% + 6% + 5% = 19%.
The improved fit to our patients’ readmission patterns is observable in the chart below:
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Following the numbers further, we determined that a 25% predicted risk of readmission
would constitute the “High Risk” threshold. As seen below, these patients constitute 20% of
our HF patients, but are responsible for nearly 40% of readmissions…
The findings of this evaluation will ultimately result in the use of the new risk assessment
model. An important consideration in use of the new model: as length of stay is a key input,
the final calculation of risk must occur on the date of discharge, or perhaps the day before,
provided the patient is expected to discharge the next day.
HF Program Care Pathway (Diagram 3)
The following is a summary of the HF Program Care Pathway. The patient is identified as
a HF patient and placed on the Daily Census Sheet which is distributed to the multidisciplinary
team. The NP initiates the RFR Sheet. If the HF Standing Orders have not been initiated they
are initiated by the NP. Per the HF Standing Orders the patient is seen and evaluated by the NP,
the TCC, Rehabilitative Services, Cardiac Rehabilitation, Dietary Services, and Care
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Management. The patient’s progress and plan of care is evaluated on a daily basis through RFR.
Prior to discharge the patient receives their < 7 day follow up appointment. The day of
discharge Pharmacy Services reviews the patient’s Medication Reconciliation Form with the
patient and Home Health HF Standing Orders are initiated.
During Transition the patient’s records are faxed to the appropriate Health Care
Provider. The NP enters the patient’s information into the HF Registry.
Post discharge- The Post Discharge Call Format is initiated. Eligible patients are seen by
Home Health within 24 hours. The patient has his < 7 day follow up appointment and is seen as
needed throughout the month. The patient attends HF University. Eligible patients begin
Cardiac Rehabilitation after completing HF University. If the patient is readmitted they are
reviewed by the Readmission Review Board.
Summary
This article describes a Heart Failure Program designed to accomplish specific
institutional goals. The Personnel involved in the HF Program, the Systems employed to provide
and improve the care of our HF target population, and a summary of the HF Care Pathway were
described in detail. Some of the difficulties encountered when developing the HF Program
were examined and the mechanisms employed to overcome these difficulties delineated. An
example of the continuing effort to evaluate the program’s efficacy and make meaningful
improvements was also included.
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References
American Heart Association. (2014, April 7). Get With The Guidelines®-HF Overview. Retrieved from
American Heart Association:
http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStrokeResus/G
etWithTheGuidelinesHeartFailureHomePage/Get-With-The-Guidelines-HFOverview_UCM_307806_Article.jsp
American Thoracic Society. (2002). ATS Statement: Guidelines for the Six-Minute Walk Test. American
Journal of Respiratory and Critical Care Medicine, 166, 111-117.
The Joint Commision. (2014, March). Advanced Disease-Specific Care Certification Requirements for
Heart Faliure (HF).
Krumholz, H., Normand, S.-L., Keenan, P., Lin, Z., Drye, E., Bhat, K., . . . Schreiner, G. (2008). Hospital 30Day Heart Failure Readmission Measure. Centers for Medicare & Medicaid Services. Retrieved
from QualityNet.org Technical Report
McIvor, M. (2007). Establishing a Heart Failure Program: The Essential Guide. Malden: Blackwell.
Rector, T. S., & Cohn, J. N. (1992, October). Assessment of patient outcome with the Minnesota Living
with Heart Failure questionnnaire: reliability and validity during a randomized, double blind,
palcebo-controlled trial of pimobendan. American Heart Journal, 1017-1025.
Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E. J., Berry, J. D., Borden, W. B., . . . Turner, M. B.
(2012). Heart Diseaseand Stroke Statistics-2012 Update: A Report From the American Heart
Association. Circulation, e102-e106.
Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, Jr, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013).
2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation, 1-125.
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About the Authors
Laura Grieve-Advanced Registered Nurse Practitioner with the Heart Failure Program at St.
Vincent’s Medical Center in Jacksonville Florida. Her tenure in the area of Critical Care and
Cardiology is 34 years. She holds a bachelor's degree in Nursing from The Ohio State University,
Vincent’s Medical Center in Jacksonville, FL. and a Masters degree in Nursing from the
University of Florida. She is certified as an Adult Nurse Practitioner (ANP-BC), a Heart Failure
Nurse (AAHFN-CB), and Acute and Critical Care Nursing Adult (CCRN).
Brooke McDuffie-Advanced Registered Nurse Practitioner with the Heart Failure Program St.
Vincent's Medical Center. Her tenure at this facility is 3 years in the area of cardiology with total
nursing experience of 13 years. She holds a bachelor’s degree in Nursing from the University of
North Florida and in Healthcare Administration from the University of Central Florida and a
graduate degree in Nursing from the University of Florida. Certified as an Acute Care Nurse
Practitioner and affiliated with the American Association of Heart Failure Nurses.
John Baker- Manager of Medical Informatics at St Vincent's Medical Center in Jacksonville, FL.
His tenure at that facility exceeds twenty years. He holds a bachelor's degree in Economics from
the University of Florida, and a graduate certificate in Clinical Informatics from Stanford
University. He has been published twice under the role of project statistician in recent years,
and has been cited as a contributor in more than three dozen graduate research articles.
Credentials include the Certified Health Data Analyst (from AHIMA), Certified Professional in
Healthcare Quality (NAHQ), and the Microsoft Certified Solutions Developer (Microsoft).
Acknowledgments
We would like to acknowledge the following two individuals for without whom this program
would have never been developed.
Dr. Steven Nauman, Chief Medical Officer, Cardiologist and HF Program supervising physician
Christine Veal RN, MSN, MBA, Cardiovascular Service Line Director during the first two years of
the HF Program.
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Diagram 1
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Diagram 2
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Diagram 3
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