Not so long ago, hospitals aimed to keep their doors open as wide as possible to accommodate as many patients as possible. No more. Soaring health care costs and health care reform have ushered in a new era that emphasizes preventing readmissions, particularly for patients with targeted chronic conditions.
University of Colorado Hospital is part of one such effort. It is one of nearly three dozen hospitals around the country involved in the Patient Navigator Program (PNP), launched in January 2015 by the American College of Cardiology (ACC). The program aims to improve overall care and reduce 30-day hospital readmission rates for patients with heart failure and acute myocardial infarctions (AMIs), two of the conditions targeted by the Centers for Medicare and Medicaid Services’ Hospital Readmission Reduction Program.
Nearly 18 months after joining the PNP, the hospital can point to some successes in standardizing the care that these patients receive. For example, the percentage of AMI patients who receive “defect-free care,” a set of performance measures approved by the ACC and the American Heart Association, rose from 65 percent in the period from September 2013 to September 2014 to 78 percent for a one-year period between April 2015 and May 2016.
Clearing the bar
Defect-free care focuses on evidence-based measures that have been shown to improve patient outcomes when they are administered as a protocol. The items include preventive medications administered at admission and discharge; promptness in getting patients to therapies like cardiac catheterization and blood clot removal; education, such as smoking cessation; and post-discharge referrals to cardiac rehabilitation.
The hospital also demonstrated notable improvement in specific defect-free care measures, including getting STEMI heart attack patients to the cath lab for treatment within 90 minutes of their arrival in the emergency department. As of mid-May, UCH had gone nearly 400 consecutive days without a miss on the so-called door-to-balloon standard, thanks to a collaborative effort involving ED, cath lab and ancillary health tech staff, as well as EMS providers.
Excellent inpatient care may go for naught if patients don’t commit to keeping their hearts as healthy as possible after they leave the hospital. In March 2015, just 31 percent of AMI patients at UCH received a referral for cardiac rehabilitation. By March 2016, the percentage rose to 95 percent, thanks to a concerted effort to identify AMI and heart failure patients while they are in the hospital and enter rehab orders before discharge.
“We used to wait to do follow-up with patients after they were discharged,” said Jennifer Holder, an exercise physiologist and supervisor for UCH’s Cardiac Rehabilitation program. “Now we’re taking the orders ourselves and getting them into the system.”
Broadening the spectrum
Each of these successes is important in its own right, but the overall goal of the PNP is to help hospitals find ways to manage care comprehensively, said Jessica Nensel, DNP, APRN, ACNS-BC, clinical coordinator for the Cardiac and Vascular Center (CVC) at UCH.
“The program allows us to look at our processes from a broad standpoint,” Nensel said. From that perspective, cardiology isn’t a stand-alone service, but rather one that relies on help from and communication with many other providers, including pharmacists, case managers, social workers, and nurses and physicians from other service lines.
“It’s important that AMI and heart failure patients get constant reinforcement and receive the same message from different providers,” Nensel said.
That message, simply put, is that the hospital is interested not only in providing a high level of inpatient care, but also in helping patients take control of their own health by watching what they eat, doing their exercise, taking their medications and keeping their follow-up appointments. These are all keys to avoiding unnecessary readmissions and emergency visits.
The PNP also allows UCH to tap the expertise of other hospitals addressing the same challenges, said Kimberly Marshall, RN, quality improvement clinical specialist with the CVC. Marshall said her team regularly joins webinars attended by colleagues from other hospitals.
“It gives us a chance to hear what other hospitals are doing and see what lessons we can learn,” Marshall said. The sessions often expose “common themes,” such as developing systems to follow up with patients after discharge and funneling more patients to cardiac rehab, she added.
Going to rehab, yes, yes, yes
A 2015 article in the Journal of the American College of Cardiology noted that while years of research have shown that cardiac rehabilitation reduces mortality and morbidity of cardiovascular disease, referral rates for the services nationally are “suboptimal.” The progress of the Cardiac Rehabilitation team at UCH underscores the point that helping patients manage their own health requires committing sufficient resources.
The team’s goal was nothing less than to capture all AMI and heart failure patients who are admitted to the hospital, enter orders for cardiac rehab and attempt to get them scheduled for classes, either at UCH or in their communities, said Carolina Martinez, an exercise physiologist with the team.
The Cardiac Rehabilitation team at UCH has tripled the percentage of AMI patients referred for services in the past year. Left to right: Jennifer Holder, Jordan, Neises, Trent Joseph and Carolina Martinez.
That meant monitoring daily the list of inpatients with a diagnosis of AMI or heart failure and beefing up staff to visit patients while they are in the hospital, begin education and assist with getting them on their feet. Five cardiac rehab staff now share the inpatient duties on a rotating basis and attend multidisciplinary rounds, Martinez said, the equivalent of a full FTE.
“Contacting inpatients has been a big priority for us, and now we have the staff to maintain that,” Holder said. “We’re also more aware of when patients are admitted and that helps us to get the orders in place.”
The inclusion of cardiac rehab providers in daily rounds has been a plus, said exercise physiologist Jordan Neises.
“The physicians introduce and present us to the patients,” she said. “It also helps us to identify patients who we might be missing.”
The staff enter orders for cardiac rehabilitation with help from nurses and physical and occupational therapists who see a patient they think is appropriate. (Heart failure patients are eligible for exercise programs and CMS will reimburse hospitals for the service, but only after patients have been discharged from the hospital for at least six weeks. There is no such requirement for AMI patients.)
The team follows up on all cardiac rehab referrals with calls to patients to schedule classes, generally the next day or at the start of the week for those admitted over the weekend, Martinez said. She also confirms that a staff member saw each patient who was eligible for cardiac rehab and if not, the reason for the omission.
Holder said the team has longer-term goals that include scheduling patients for rehab before they are discharged. That could be accomplished by including a patient access representative in daily rounds, she said. Another aim is to assign a single cardiac rehab staffer to the inpatient units.
“That would make it easier for us to follow patients from start to finish,” Holder said. “It would also give us a face that providers would more easily recognize and associate with cardiac rehab.”
As Martinez noted, however, these steps, however carefully planned, won’t improve outcomes unless patients take a hand in their own care. “We can help them, but following up is also on them,” she said.
No magic bullets
The uncertainty of patient involvement may help to explain why, nearly a year and a half into the PNP, the hospital has had only modest success in reducing the 30-day readmission rates for heart failure patients, from 19.3 percent in fiscal year 2015 to 18.9 percent. The decrease for AMI patients for the same period was greater, from 12.5 percent to 10.8 percent, but in both cases the challenges are formidable, Marshall added.
“Patients only hear about 10 percent of the information we give them when they leave the hospital,” she said. “Follow-up with education is huge.”
But how best to do that? Nensel points out that some community hospitals have full-time navigators to assist all their patients through discharge and beyond. That’s a challenge at large hospitals like UCH with multiple service lines and many patients with complex conditions compounded by nonclinical problems.
“When we review our AMI and heart failure cases, we frequently find that socioeconomic issues are the greatest barriers to care,” Marshall said. “We are working with case managers on transitions of care. That’s something that all health care organizations in the country are trying to get a handle on.”
One initiative under consideration at UCH is follow-up phone calls to patients within 72 hours of discharge to schedule follow-up clinic appointments, check medications, and identify potential barriers to care.
“Some facilities have implemented follow-up phone calls and have seen how it trickles down to the readmission rate. This is an initiative we plan to explore and see if we can adapt that approach into our current processes,” Nensel said.