See You in 7

In cardiology we need to measure our achievements by what we have done for patients and populations. It is not enough to brag about new programs provided or treatments delivered. In the end we need to know the results we have achieved.

Such information, however, is not easy to obtain. We do not have the type of integrated national data that would provide a surveillance system. However, the Medicare Fee-for-Service system does have records stretching back more than a decade that can be accessed and analyzed to determine trends in hospitalization rates and outcomes.

Yun Wang, PhD, Sharon-Lise Normand, PhD, FACC and I embarked on a study to provide some perspective on what we have achieved in cardiovascular medicine. We just published the results in Circulation and they are breathtaking. We found that hospitalizations for acute cardiovascular disease and stroke showed rapid decline from 1999 through 2011, compared to other cardiac-related conditions. While the other conditions changed very little, the acute myocardial infarction (AMI), heart failure and stroke admissions declined by about a third and unstable angina by more than 80 percent. Additionally, patients achieved improved mortality and readmission outcomes. In AMI mortality, in particular, the 30-day mortality rate declined by about a third – but heart failure also decreased by almost 20 percent.

And what about readmission? We have had gains there too. There was a 19 percent decline in 30-day readmissions for AMI, 10 percent for heart failure, and 7 percent for stroke.

What is interesting is that this improvement occurred in the absence of new blockbuster drugs or interventions. It occurred in a period where we intensely sought to improve the quality of care and make more with the knowledge we have. It was also a time of intense efforts to promote healthy behaviors. Improvements have included the identification and treatment of hypertension, a significant rise in the use of statins, and declines in smoking. Improvements have also been made in the use of evidence-based medications and the timeliness of treatment for patients with ST-segment elevation myocardial infarction. Additional factors also include the use of registries and other data to track performance and support improvement efforts.

This success should not make us complacent – rather it should encourage us to continue along this path.

For those committed to reducing readmission risk, the ACC is a great partner.

The ACC Quality Improvement for Institutions program is putting proven strategies and tools for improving outcomes in the hands of cardiovascular care providers across the country. Hospital to Home (H2H), one of the initiatives under the program, has a long track record of helping hospitals reduce readmissions and improve transitions of care by sharing best practices and disseminating evidence-based strategies and toolkits. When hospitals address readmissions head on by participating in initiatives such as H2H, I think we will continue to see improvements in readmission outcomes overall.

Get started on the road to reducing readmissions. The complete See You in 7 challenge project is now ready to be implemented. Check out the new Mind Your Meds assessment and toolkit to identify opportunities for improvement and implement strategies for optimal medication management. Additionally, register for the upcoming H2H Signs and Symptoms Tools and Strategies webinar on Sept. 11 at 1 p.m. ET.

This post was authored by Harlan M. Krumholz, MD, SM, FACC, member of the ACC Board of Trustees. Originally posted on the ACC in Touch Blog on September 3, 2014.

With heart failure (HF) readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with Michigan’s Quality Improvement Organization, MPRO, and the Great Detroit Area Health Council to form the Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.” This post is part of a series on H2H at the local level.

Our HF team at the Ann Arbor Veterans Affairs (VA) Health System now consists of a cardiologist specializing in HF, 2.5 nurse practitioner full-time equivalents, and a cardiology pharmacist. Three years ago, our median time to first appointment for our post-discharge HF patients was over three weeks and our 30-day readmission rates were unacceptable. Like many of the other “See You in 7” participants, we had already started quality improvement efforts prior to the collaborative but learned a lot from the experience. Many of the other hospitals were dealing with multiple cardiology practices, communication challenges, and difficulties with reimbursement for follow-up. The VA, by contrast, is a self-contained system with no reimbursement issues and a longstanding electronic health record (EHR) system that makes inter-provider communication straightforward. However, we see patients from a wide area that includes most of Michigan and northwest Ohio, and many unfortunately have severe socioeconomic difficulties.

Our effort focused on two central issues: 1) primary care and cardiology did not have availability for timely post-discharge appointments, and 2) we were not effectively identifying HF inpatients. We created a post-discharge clinic led by our pharmacist where patients receive education, medication reconciliation, and an exam by a cardiologist or nurse practitioner. Clinic volume improved significantly after we enlisted our internal medicine inpatient team case managers to facilitate referrals and notify the HF team of the admission through the EHR. Our median time to post-discharge follow-up has significantly decreased, and identifying patients early in their stay has helped uncover potential problems with transportation, finances and poor social support. Our post-discharge clinic experience has pointed out gaps in discharge education, which we have started to rectify via a commercially-produced HF video that we provide to all discharged patients. We will soon implement tools for readmission risk stratification into our HF database, and have developed a questionnaire to facilitate management of non-cardiac comorbidities that may affect readmission risk. Using lessons from “See you in 7,” we have established a collaborative within our VA region and aim to develop strategies to reduce readmissions across all VA facilities in our area.

Get additional perspectives from the Southeast Michigan “See You in 7” Hospital Collaborative here.

This post was authored by Scott Hummel, MD, FACC, from the VA Ann Arbor Healthcare System. Originally posted on the ACC in Touch Blog on December 9, 2013.

The ACC and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) have a longstanding relationship, and as a result, have developed a variety of tools for physicians and their patients to use to encourage participation in cardiovascular rehabilitation (cardiac rehab).

As clinical practice guidelines highly recommend cardiac rehabilitation after cardiac events such as a myocardial infarction to improve mortality, quality of life and functional capacity, the ACC’s Hospital to Home (H2H) program stresses that it is important for a patient to have a referral for a cardiac rehab program within 7 days following discharge after a myocardial infarction. This recommendation is not by chance – there is now good evidence showing that the sooner a patient enrolls in cardiac rehab, the better their likelihood of attending regularly, which will then lead to better outcomes. There is also evidence that participation in cardiac rehabilitation improves adherence with preventive medications and decreases depression and anxiety.

Just in time for Cardiac Rehabilitation Awareness Week, the ACC and AACVPR worked together to update the cardiac rehab resources in the “See You in 7” toolkit available on the H2H website. The resources allow for managers, nurses, and others working on care coordination to appropriately incorporate cardiac rehabilitation into patients’ treatment to help decrease readmissions related to misconceptions about medications or symptoms.

In order to emphasize the importance of cardiac rehab, the ACC and the AACVPR have developed multiple resources for several of the success metrics of the H2H “See You in 7” challenge, including highlights of the 2010 ACC Foundation (ACCF)/ American Heart Association/ AACVPR Cardiac Rehabilitation Performance Measures. In addition, CardioSmart.org has a great overview of cardiac rehab on its newly redesigned website, in addition to a cardiac rehab fact sheet developed by AACVPR available in both English and Spanish, and a CardioSmart Video: Journey Back to Heart Health, about cardiac rehab that can be used in office or hospital settings.

Smart cardiac rehab teams will be making sure that others working on hospital readmissions in their community are aware of H2H and of the materials within the H2H website that can be used to promote cardiac rehab enrollment. It’s time for ACC and AACVPR colleagues within local communities to meet to figure out how and when to use this information, in order to break down barriers to participation in cardiac rehab and improve patients’ health outcomes.

This post was authored by Marjorie King, MD, FACC, MAACVPR, past president and chair of the Professional Liaison Committee of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Originally posted on the ACC in Touch Blog on February 13, 2013.

Last week I joined ACC President John Gordon Harold, MD, MACC, and other College leaders at the 24th Great Wall International Congress of Cardiology (GW-ICC). It was truly an honor to be a part of this remarkable event. For me, the meeting’s focus on “Integrated Medicine” was particularly opportune given that it fits nicely under the theme of “Transformation of Care” – one of the five main themes the College is addressing as part of its strategic planning process.

Integrated medicine, team-based care, is emerging as a partial solution to helping members address and overcome the disruption caused by the clinical and economic changes in the health care environment and ultimately transform the delivery of cardiovascular care. Not only does team-based care have the potential to address shortages in the cardiovascular workforce, it also shows promise for enhancing the quality and safety of patient care and expanding physician productivity and job satisfaction by reducing workloads and preventing burnout.

Surveys of ACC members over the last few years support these claims. Of the practices operating in a team-based care environment, increased efficiency, improved quality of care and increased patient satisfaction were the primary improvements cited. Other benefits of the team approach include increased staff satisfaction and in some cases improved financial outcomes.

Improved quality is one of the biggest benefits of integrated medicine. ACC surveys show that cardiovascular professionals in hospital or academic settings are more likely to engage in quality improvement types of team-based care, including participation in data registries and quality improvement projects like the College’s Hospital to Home initiative (H2H). In China, Dr. China 2013 Harold highlighted the particular value of H2H in bring in bringing together integrated teams to change the way we practice cardiovascular medicine for the better.

Moving forward, defining the optimal approach to team-based care and identifying the roles of cardiovascular specialists within the health care continuum, particularly as it relates to primary care, will undoubtedly be a strategic priority for the College. Helping members thrive and deliver high quality, patient-centered, cost effective care in any delivery and reimbursement environment is at the heart of the strategic plan and integrated care is one way we can get there.

This post was authored by Shal Jacobovitz, CEO of the ACC. Originally posted on the ACC in Touch Blog October 18, 2013

With heart failure (HF) readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with Michigan’s Quality Improvement Organization, MPRO, and the Great Detroit Area Health Council to form the Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.” This post is part of a series on H2H at the local level.

At Crittenton, we have worked on reducing readmissions since 2009. The “See You in 7” Collaborative was a welcomed opportunity to share ideas with others, specifically in the context of HF. We have a strong HF program, and have assembled a great team of professionals committed to improving our outcomes. Preventing unnecessary readmissions is a key component of improving outcomes, as well as improving our patients’ quality of life.

The collaborative gave us the framework and the freedom to work on the issues we felt would be most beneficial for us. We focused on the following:

• Identify and address barriers to keeping follow-up appointments for all HF patients
• Ensure all HF patients arrive at their appointments within seven days of discharge
• Make the discharge summary available to follow-up care providers of all HF patients

We focused on processes that patients face in keeping their post-discharge appointments. Data was gathered from the medical record and from interviews with HF patients and their caregivers. Primary care physicians and cardiologists were surveyed to determine whether their practice schedules could accommodate appointments within a week of discharge. We then surveyed physicians to discover if they typically have a discharge summary or other pertinent clinical information at that first office visit post-discharge.

We discovered that many HF patients have transportation difficulties. This led to the publication of a comprehensive transportation guide now used for all patients throughout our facility. The time frame for discharge summary completion was shortened so the summary can reach the post-discharge care provider more quickly. In addition, we discovered that a discharge process we had developed in 2009 for appointment setting prior to discharge wasn’t working well, so we made some process changes and continue to improve in this area today.

One of the most important lessons we learned as participants in the collaborative is that once a process is put into motion to address a problem, we can’t simply assume that the process continues to work flawlessly. We now re-check process compliance to ensure continuous decline in readmissions for HF.

Stay tuned for other perspectives from the Southeast Michigan “See You in 7” Hospital Collaborative.

This post was authored by Jacqueline Jones, MSN, APN-BC, CEN-CEN, manager of NP/PA cardiovascular services at Crittenton Hospital Medical Center; Jill Klaver, JD, RHIA, medical staff quality specialist at Crittenton Hospital Medical Center; and Samer Kazziha, MD, FACC, executive medical director, cardiovascular program at Crittenton Hospital Medical Center. Originally posted on the ACC in Touch Blog on October 28, 2013.

With heart failure (HF) readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with Michigan’s Quality Improvement Organization, MPRO, and the Great Detroit Area Health Council to form the Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.” This post is part of a series on H2H at the local level.

Beaumont Grosse Pointe is a 280 bed community hospital and it was felt we might have an easier time getting our arms around the HF readmission issue due to our size. We chose the metrics we thought would have the biggest impact:

1. Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within seven days after discharge
2. Providing the patient with documentation of the scheduled appointment
3. Working to ensure that the patient arrives at the appointment within seven days of discharge

We had buy-in from our cardiology practices regarding accommodating appointments in the offices within seven days, which was a huge benefit to us. Additionally, the Administration supported our efforts and worked with our health system’s Home Care division to position a nurse in the hospital with experience in HF to assist in our efforts. She scheduled the appointments and made follow-up calls to the patients. She also compiled a list of transportation resources for these patients due to their challenges getting to appointments and did a great deal of one-on-one teaching with this patient population.

We already had a robust HF calendar for patient teaching purposes, but our challenge in the beginning was identifying HF patients in-house, as admissions from the EC are frequently listed as “shortness of breath,” or “lower extremity swelling,” or something of that nature with no mention of HF until they are coded on the back end. Also, there are patient lists generated from the electronic medical record (EMR) as well as from the Care Management documentation system, but no one real “source of truth.” As such, the system recognized the issue and all three hospitals along with IT Informatics are working on building a HF patient list that queries the system for things like SOB or swelling as an admitting diagnosis, pharmacy order for loop diuretics, and others cues. However, the process has had its challenges, including no easy way to mine discreet data fields such as the ejection fraction on an echo report (due to the fact that the echo report is linked in the EMR from a different template platform). We continue to work on this project.

Another challenge was having reliable contact information from the patient and caregivers so discharge contact could be made to verify appointments were kept. Finally, due to resource allocation, it was a challenge following patients who were discharged over the weekend.

We have seen some success in terms of decreased readmission rates for HF and are cautiously optimistic. We will continue to refine the work we do and hopefully offer any best practices we have developed to other chronic disease integration teams across our hospital and system.

Stay tuned for other perspectives from the Southeast Michigan “See You in 7” Hospital Collaborative.

This post was authored by Marie Boyle Reinman, RN, director of heart and vascular services and critical care nursing at Beaumont Hospital in Grosse Pointe, MI; and Sarine John-Rosman, MD, FACC. Originally posted on the ACC in Touch Blog on November 25, 2013.

With heart failure readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with other local organizations to form the Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.”

Serving on the planning team for the Southeast Michigan “See You in 7” gave me the opportunity to see first-hand how hospitals, quality improvement organizations, and other health care groups can work together and make a true impact on reducing readmissions on the local level. The goal of the year-long collaborative was to create a vehicle for candid sharing of individualized strategies, successes and barriers, to reduce 30-day heart failure (HF) readmissions. Members chose process measures from the H2H “See You in 7” toolkit. Five key features helped the collaborative meet their goal:

1. The right people at the table to tackle the problem
2. A framework that facilitated creating action plans that could be measured
3. Inside and outside experts to share the latest innovations and to think about how to tackle reducing HF readmissions
4. Quarterly feedback to track progress and reappraise the need for a change of direction
5. The formation of a collegial bond between participants in order to express and share during the collaborative

Many groups of dedicated people made this project a success. Collaborative participants included CCAs and FACCs on the ACC Michigan planning committee who contributed to hospital recruitment and provided multidisciplinary conceptualization of the project. The Greater Detroit Area Health Council provided executive leadership, meeting space and electronic communication and webinar support by virtue of a Robert Woods Johnson Foundation grant. The ACC H2H team provided the “See You in 7” framework. MPRO, Michigan’s Quality Improvement Organization, provided hospital data on follow-up within seven days and 30-day readmission rates. But in my reflection, the collaborative success rests squarely with the teams from the 12 participating hospitals.

Member hospitals, although varying in size and location (urban and suburban) and range of resources available via their individual HF programs, created an atmosphere of sharing informative feedback about best care and utilization resources to innovate and surmount readmission barriers.

After a year of collaboration and implementation, did readmission numbers budge? Preliminary findings show hospitals that participated in the collaborative reduced 30-day HF readmissions by 10 percent, while hospitals across the state averaged 7.2 percent reduction during the same time period. These findings are encouraging and pave the way for other readmissions projects in other communities. We’re looking forward to seeing the complete results in the fall.

I hope you found my reflections on our collaborative inspiring and helpful. It is truly amazing what we can accomplish when we work together with a common goal. Watch for future blogs from our collaborative hospital team members as they share member insights from their “See You in 7” experiences too.

This post was authored by Joy A. Pollard, PhD, RN, ACNP-BC, Southeast Michigan “See You in 7” Hospital Collaborative planning committee member. Originally posted on the ACC in Touch Blog on August 29, 2013.