Annotated Bibliography For Heart Failure

"Reducing 30-Day Readmissions for African Americans with Congestive Heart Failure by improving health literacy through a Comprehensive Context Oriented Discharge Plan”

The Affordable Care Act (ACA) added to the Social Security Act has increased the financial accountability of healthcare organizations for preventable readmissions. Hospitals have increased their awareness and are looking for system ways to assist in the reduction. The Centers for Medicare and Medicaid Services (CMS) have initiated a process for decreasing the reimbursement for readmitted patients within a 30-day period. CMS identified readmission measures for applicable conditions of acute myocardial infarction (AMI), heart failure (HF), pneumonia and in 2015 chronic obstructive pulmonary disease (COPD) and hip and knee replacement which are included within the measurement to calculate the readmission payment adjustment for

Hospitals nationwide have been striving to reduce the rate of patient readmissions. Both the federal government and private insurers are tired of picking up the tab. In a 2009 study in the New England Journal of Medicine, researchers estimated that a year's worth of unplanned re-hospitalizations cost Medicare alone $17.4 billion. Congestive heart failure is a particularly big target, as one in four patients end up back in the hospital within 30 days of discharge. Starting in the fall of 2012, the government will cut Medicare reimbursements for hospitals with higher-than-expected 30-day readmission rates for heart failure and two other conditions: heart attack and pneumonia (Avril, 2011).

There is a problem of avoidable hospital readmission rates for the Medicare and Medicaid populations that lead to adverse consequences not only for the patient, but also the payer and hospital. In order to decrease these avoidable readmission rates it is important to identify processes that can be implemented at the health plan level such as pre-discharge hospital visits by health plan staff, and post-discharge care coordination.

Congestive heart failure is a growing chronic condition in the United States that accounts for over one million hospitalizations and is responsible for 27% of patients with heart failure on Medicare are readmitted with 30 days of discharge (Hines, Yu & Randall, 2010). The intensity of the disease process poses a financial strain on both the patient and the payers, especially Medicare, as 10 per 1000 population are 65 years or older and therefore a Medicare beneficiary (Mozaffarian et al., 2015). Consequently, in order to gain control over this chronic disease and its cost burden, the government and policy makers have shifted the responsibility to the health care facilities through the creation of policies that affect hospital reimbursement based on readmission rates. As a member of the quality team at my facility, the Hospital Readmissions Reduction Program deeply impacts my practice and encourages the hospital as a whole to focus on improving multidisciplinary collaboration in pursuit of quality patient care, resulting in better outcomes and decreased readmissions.

the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization. American Heart Journal, 164(3). 365-372. Retrieved from: http://www.medscape.com/viewarticle/771215_print

Policy makers created the Medicare Hospital Readmissions Reduction Program (HRRP) in an attempt to improve quality of patient care and lower costs (James, 2013). In order to avoid these penalties, healthcare leaders must recognize that CMS has identified a correlation between readmissions and a lack of quality care. Therefore, the aim is not to focus solely on hospital readmissions, but to seek clinical excellence by investing in quality improvement (Silow-Carrol, Edwards & Lashbrook, 2011). However, reducing readmissions is a complex undertaking, because not all readmissions can or should be prevented. Indeed, some readmissions are planned as part of sound clinical care. Furthermore, while hospitals work to reduce readmissions caused

CMS 30 day-readmission penalties have motivated hospital to reevaluate discharge planning in hopes to reduce 30-day readmissions. Lopes et al. (2015) used the CRUSADE registry to evaluate causes associated with 30-day readmissions. This study included 36,711 patients with non-ST segment elevation myocardial infarction, age > 65 enrolled February 15, 2003 – December 29, 2006. This study evaluated comorbidities and cumulative incidence of readmissions over one year and found that readmissions with the very elderly having 50% mortality rate at 1 year which was thought to be impacted by co-morbidities, deconditioning and avoidance of core measure post-MI medications for various reasons. The final conclusion was that

Policy makers are constantly searching for new innovative ways to increase quality patient care and lower Medicare program spending. One indicator of inadequate quality that results in increased Medicare spending is the rate of readmissions to the hospital. Heart Failure patients are on the top of that list. Readmission refers to a patient’s being hospitalized within 30 days of an initial hosptial stay. This seems to be an indicator of inadequate quality of care in the hospital or a lack of appropriate coordination of postdischarge care.

A hospital readmission is defined as one that occurs when a patient is admitted to a hospital within a specified time period after being discharged from an earlier (initial) hospitalization. For Medicare, this time period is defined as 30 days. Some of the quality care issues arise within the hospital among staff and also at home after patient discharge. Some of the highest rates of readmission within the 30 days are related to some of the following factors: complications from treatments during a hospital stay, inadequate treatment/inadequate care, coordination and follow up care at home and unexpected worsening of the disease after discharge from the hospital. Patients often face challenges with medication compliance and administration, not understanding the nature of their disease, and also where to get their questions answered once at home. The health care system has come to the conclusion that most of these issues is the leading factor in patient readmission. The most cost efficient solution to the problem of avoidable readmissions is patient education and after discharge follow up. Providing discharge instruction pamphlets to patients is not adequate enough information to yield results. Often times it is left with the patient’s belongings in a bag and never read. This gap in quality care is costing hospitals

Congestive heart failure is a chronic condition that is responsible for the highest number of hospitalizations among adults. Readmission rates after hospitalization also remain high, with 50% of patients being readmitted within 6 months of discharge. (Desai & Stevenson, 2012). The Affordable Care Act penalizes hospitals with readmissions within 30 days after discharge, making readmissions a focus of hospitals nationwide. Several factors including discharge planning, patient education, diet restrictions, and early follow up appointments can help to reduce readmissions, but continuous monitoring is necessary to catch early signs of decompensation. (Desai & Stevenson, 2012).

This project was an observational program evaluation. The purpose of this project was to evaluate 30-day readmission, medication compliance and outcomes of patient who received traditional care (services provided prior to October 1, 2015) to that of patient who received care from Post Myocardial Infarction Transitional Care Program and Advanced Practice Provider Transitional Care Clinic (which started October 1, 2015). This project focused on evaluation of the following questions:

Finding ways to decrease readmission for patient with a chronic disease process has brought about change with the use of technology. As of October 2012 hospital are penalized 1% from Medicare for every patient who have excessive readmission for certain chronic disease such as pneumonia, acute myocardial infarct (AMI), and chronic heart failure (CHF) in addition to the amount increase by 1% for the following two years (ACEP, n.d.). Engaging and monitoring patients with chronic disease outside the hospital include supplying a patient with CHF with an I Pad, blood pressure monitor, digital scale, pulse oximetry, and hand held heart monitor provides data. The patient checks in daily from home and the data is analyzed to determine if any intervention

“With shorter hospitalizations and high patient loads for both physicians and nurses, discharge planning is often hurried and incomplete” (Balaban, Weissman, Samuel, and Woolhandler, 2008). After reviewing national surveys regarding hospital discharge, they found that only 50% of patients with congestive heart failure received any sort of written instructions at the time of discharge. Other information revealed most patients were unaware of their discharge diagnosis, misunderstand the use of new medications, and receive insufficient discharge care, all of which are major contributors to hospital readmissions (Balaban et al., 2008). They proposed a similar model with the same goals and their findings supported the use of some sort of designated discharge coordination that connects the hospital and community, they were able to divert a significant number of revisits to the hospital for issues that had already been addressed and patients were simply uneducated regarding their condition or proposed treatment plan. Another study where the hospital set up an actual discharge clinic reported that in the first six months of operation they were able to “reduce emergency room visits and readmissions for targeted patients by 68%” (Beresford, 2011).

The Cardiac Rehabilitation (CR) model has been developed to encourage greater utilization of post-acute treatment for AMI or CABG patients in the 90-day post-discharge period. The goal of the models is to improve the quality of care for several heart conditions and surgery on hips other than total hip replacement.11 After the success of CJR, CMS expects the EPM and CR programs to significantly increase quality and reduce cost by the same principles. Moreover, while the mandatory programs show promise, voluntary-based bundle-based programs are also improving value-based care. For example, a study evaluating AMI, heart failure, and pneumonia demonstrated that hospitals that participated in these Medicare value-based programs led to a reduction in thirty-day standardized readmission rates.9 This study suggests that even in the absence of a mandatory episode of care based payment model, it may be to a hospital’s advantage to consider these programs as they may lower cost while increasing quality of care.