Individualized Care Using Standard Work

(May 2016) Health care is undergoing a radical change. The percentage of Americans aged 65 or older is expected to reach 20% in the next decade, and with an aging population comes an increase in chronic disease and rising health care costs. As a result, the health care landscape has shifted toward a multidisciplinary approach that emphasizes the coordination and monitoring of patients across the continuum of care.

At University of Colorado Hospital, the heart failure team is working hard to meet this challenge by evolving into a disease-specific center of excellence, focusing on value-based, patient-centered care.

Larry Allen, MD,  is medical director of the advanced heart failure and transplantation program. He explains that there are many moving parts to caring for these patients.

“Heart failure simply means the function of the heart is suboptimal – the blood is not pumping as it should – and it can be a result of many different problems that become more common as patients get older,” he said. “Not surprisingly, many have multiple comorbidities and are cared for all over the hospital.”

Dr. Allen and his team have been working to improve their processes and reduce readmissions for many years, but the introduction of the Affordable Care Act and subsequent value-based purchasing program in 2012 provided an extra impetus. This program brought penalties for too many readmissions. Since heart failure is one of the most common reasons for readmission, UCH could be hit hard.

An estimated 5.8 million Americans have heart failure; 46% of whom have Medicare. Heart failure accounts for more than 1 million hospitalizations per year and is the most common reason for hospitalization among Medicare patients. Of those who are hospitalized, nearly a quarter are readmitted in 30 days or less. Yet as Amanda Nenaber, DNP, ACNS-BC, explains, the factors that affect readmissions are multi-faceted.

“Often patients are readmitted for socioeconomic factors – something we have less control over. These readmissions are usually not preventable, and while our readmit rate is consistently at or below the national average, we really focus on the quality of care we’re providing and analyzing why people do or do not return to the hospital.”

Dr. Nenaber  is the heart failure program manager at UCH and manages the care of the 500+ patients admitted with heart failure each year. One of her biggest successes is the UCH Heart Failure Committee, which she chairs. The committee includes physician and nursing teams, physical and occupational therapists, care coordination, nutrition and pharmacy services, and quality and data analysts.

“The committee meets monthly to discuss current initiatives and quality metric performance, identify gaps in care and execute continued program improvements to transform care innovatively,” Dr. Nenaber said. “In addition, we review every readmission to look for trends in what we could be doing differently.”

Such a multidisciplinary approach is essential to improving the quality measures for a population whose care is spread out across the hospital. Yet appropriate care has to start at admission.

“The average hospital stay for heart failure is five days,” said Dr. Allen. “If we manage to identify the patient on day one we have a far greater chance of delivering effective education and care. However, it can be difficult to know in real-time who in the hospital will end up with a primary discharge diagnosis of heart failure, and so we created an algorithm in Epic, our electronic health record system, to identify patients who were admitted in the past 24 hours and met certain criteria.”

Dr. Allen and his team also used the electronic health record to calculate a risk score for patients with heart failure. This allowed them to better allocate their resources to make sure the right patients receive the right care.

“This improvement enabled us to provide education via our in-hospital pharmacists and nurses, to have case managers and social workers sit and talk with the patient about their home situation and to arrange for therapy and dietician support,” Dr. Allen said. “It meant we could bring people together who had a common interest in caring for this population.”

In addition to identifying and assessing heart failure patients, the team also created a best practice alert in Epic that prompts heart failure order sets at admission and discharge to standardize care. The usage of these order sets is now up to 80%.

For Dr. Nenaber, much of the success of the heart failure program depends upon her ability to build relationships with care providers across the hospital and into the post–acute care network.  

“We’ve known all along that if we are truly going to make an impact on readmissions we have to establish relationships and collaborate with the community and our clinics,” she said. “For example, we’ve spent a lot of time partnering with case management to identify home health agencies that have heart failure care pathways so we can continue focused patient care long after discharge from the hospital.”

Indeed, something that sets the heart failure team apart is their ability to look at the bigger picture.

“If we want to be leaders in population health we have to step beyond just heart failure care and partner with other disciplines and patient populations,” Dr. Nenaber said. “This involves having lots of conversations with clinicians at all levels about how we can move forward together.”

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