Hudson Valley Hospital Center Heart Failure Project

1. Hudson Valley Hospital Center Heart Failure Project A collaborative approach to improving heart failure care

2. Hospital to Home (H2H) • A national quality improvement initiative • Sponsored by the American College of Cardiology (ACC) and the Institute of Healthcare Improvement (IHI) • Purpose: to reduce cardiovascular-related hospital readmissions & improve transitional care from hospital to home • Strategic partnerships are encouraged as a vehicle for improving care and outcomes

3. HVHC Heart Failure Task Force Purpose: To improve the care delivered to heart failure patients across the continuum

4. Members of the HVHC HF Task Force • Myrna Cuevas RN, Esq • William Higgins MD • Maggie Adler RN-C • Jennifer Fell RD • Ann Marie Beall DPh • Visiting Nurse Association of Hudson Valley

5. ACE Star Model

6. ACE Star Model & EBP Process PICO Question: • What interventions for heart failure patients help decrease their rehospitalization and mortality rates?

7. Knowledge Discovery & Evidence Summary Literature Search: Research Studies, Guidelines, Stats AHA, ACC, IHI, AHRQ, CMS

8. Facts on Heart Failure • 50% readmission rate within 6 months • 25% to 35% incidence rate of death at 12 months

9. Facts on Heart failure • The mortality rate for women with breast cancer is 1 in every 29 deaths, the mortality rate for women with cardiovascular disease is 1 in every 2.4 deaths

10. Trends in Hospitalization for Heart Failure by Age Group 1979-2004(CDC, 2006)

11. CMS Quality Measures: Heart Failure (HF) 100% compliance with the following evidenced-based guidelines: • Discharge instructions • diet • MD f/u • weight monitoring • worsening s/s • Medications with reconciliation • Left ventricle systolic function evaluation • ACEI/ARB for LVSD • Smoking cessation counseling

12. Heart Failure at HVHC • Heart failure is the second highest DRG • Average costs per patient per day $2,000 • Average LOS is 6 days • 30 day readmission rate is 24.2%, national rate is 24.5% (HHS, 2008) • Mortality rate is 9.7%, nationally it is 11.1% (HHS, 2008)

13. Translation into practice Clinical Expertise to translate your findings into practice

14. How can we improve practice? • Standardize treatment plans for heart failure • Standardize patient education for heart failure • Case Management referral for heart failure patients to Telehealth program at VNA • Collaborate with the Visiting Nurse Association of Hudson Valley (VNA) • Collaborate with community based physicians

15. Integration Integrating your findings into practice

16. Evidenced-based Recommendations promote a reduction in rehospitalization and mortality for patients with heart failure (IHI, AHRQ, ACC) Physician Order Set LVSF assessment ACEI or ARBs Beta Blockers Anticoagulants for atrial fibrillation Diuretics Lab assessment Influenza & Pneumoccocal vaccination Diet and fluid restriction Daily weights Exercise/activity tolerance Smoking cessation counseling Patient education Case management & Nutrition referral (ACCF/AHA, 2009; AHRQ, 2009) Standardize Treatment

17. Considerations in Treatment of Special Populations • Elderly patient's have an altered ability to metabolize or tolerate medication therapy • Isosorbide dinitrate and hydralazine is recommended for African-Americans in addition to standard heart failure treatment • 50% of Asian patients develop a ACEI induced cough • Majority of patient’s with heart failure are women

18. Standardize Patient Education • Provide education literature from the AHA • Document education completed in EHR • Revise Discharge Instruction sheet to include HF care instructions • HF education reinforced by VNA nurses • Future: In CPOE create notification link from physician order for HF education to nurses task list

19. Heart Failure (HF) Screening Flow Chart Present to ED No Health Care Services Provided N HF symptoms w/i 1 year and/or present HF symptoms and/or R/A 31 days with previous HF diagnosis Case Manager assesses patient for homecare or skilled nursing need. Admit as Inpatient N Y Case management evaluates patient/ Family/caregiver’s goals Collaborates discharge plan with patient and health care team Y Homecare or skilled nursing referral made

20. Telehealth Program • Screening for eligibility will be performed by the VNA while the patient is hospitalized • Remote home monitoring will include vital signs, oxygen level assessment, and weight • Patient education provided by VNA nurses will reinforce education provided by HVHC nurses • Telehealth visits are in addition to regular home nursing visits

21. Interdisciplinary approach Physician Order Set Patient Education Comprehensive discharge instructions Telehealth program Collaboration across the continuum of care Increase in patient self-management skills Increase in patient satisfaction Decrease variation in care delivered Decrease LOS from 6 to 4 days Decrease 30 day readmissions to 16% Decrease mortality by 10% Accomplishments & Outcomes of the Heart Failure Project

22. Evaluation HF Readmission & Mortality rates

23. Heart Failure Readmissions Heart Failure Task Force Update: • Total 27 HVHC patients referred to Visiting Nurse Association Hudson Valley in 10 months (9/09 – 06/10) • Readmission rate: 11% • HVHC Goal: 16%

24. Future Opportunities for Collaboration

25. Improving Care at HVHC At HVHC we are dedicated to caring for our patients across the continuum…….

26. References • Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP: ACE Star Model of EPB: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. Retrieved July 8, 2009, from http://www.acestar.uthscsa.edu • Centers for Disease Control and Prevention. (2006). Heart Failure Fact Sheet. Retrieved August 16, 2009, from the CDC on the World Wide Web: http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf • Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/American heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT • Institute for Healthcare Improvement (2008). 5 Million Lives. Getting started kit: Improved care for the patients with congestive heart failure.Retrieved July 19, 2009, from IHI on the World Wide Web: http://www.ihi.org

27. References • Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2009). 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology foundation/American Heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT • National Guideline Clearinghouse. (2007). Heart Failure in Adults. Retrieved July 20, 2009, from NGC on the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+AND+Failure • Schroetter, S. A., & Peck, S. D. (2008, April). Women’s risk of heart disease: Promoting awareness and prevention-a primary care approach. MEDSURG Nursing, 17(2), 107-113. • U. S. Department of Health and Human Services. (2009). Hospital Compare-A quality tool provided by Medicare. Retrieved July 19, 2009, from HHS on the World Wide Web: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE%7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home