Background: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. By 2030, greater than 8 million Americans will be living with HF. The projected cost will increase to close to 70 billion with the majority of the cost attributed to hospitalization. Despite numerous evidence-based strategies in the literature to reduce HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days.
Purpose: The UPMC Pinnacle Cardiology and Hospitalist leadership analyzed HF data and proposed an opportunity for improvement based on HF metrics. All parties recognized the need to foster consistent inpatient provider care that was lacking in the current model. The concept of a dedicated Heart Failure Hospitalist service line emerged. Intensive literature review revealed that this specific care model is virtually non-existent.
Description: Patients with both primary and chronic HF: UPMC Pinnacle Hospitalist & Cardiologist N=992 (74%); CHF Team N=351 (26%). 12 monthsKey initiatives for success:Extensive time is spent educating about heart failure, medications, monitoring daily weights, fluid restrictions, and recognition of early signs and symptoms. Personalized post discharge action plans are developed and documented in the medical record. Coordination of care with outpatient services: Heart Failure Center & Community Para-medicine.Transitioning to Hospice Care: UPMC Hospitalist & Cardiologist 5.9% vs CHF Team 13.1%. All cause readmission at 9% (58.9% Relative Reduction compared to National Average). Cost Savings=$265,356 in 1st year of service line
Conclusions: Although, prevention of readmissions is an overarching goal, readmissions do happen. With the current care hospital model, HF patients rarely have a consistent provider if readmitted. Lack of consistency reduced the ability to develop trusting relationships which are essential to facilitate goals of care discussions. To address this health care priority at UPMC Pinnacle with approximately 1,200 HF patients annually, an interdisciplinary HF team created a HF Hospitalist service to support an environment of patient centered care across the continuum by providing continuity of care for HF admission and HF patients admitted for non-HF admissions. The HF Hospitalists provide quality care with frequent daily rounding, optimization of HF medications, patient and family education to improve treatment plan adherence and early discussion of palliative and hospice transition. The goal is early post-hospital provider follow-up to aggressively monitor HF patients. The HF Hospitalist team meets daily with HF Nurse Navigators to support the system’s outpatient self-management program which uses an 8-visit template to review action plans, goals of care, medication reconciliation and education. The team also implemented innovative techniques such as Community Paramedicine outpatient visits to carry out intravenous diuretic protocols in the home, virtual/telemedicine visits, and ReDS-VEST technology to monitor for signs of early exacerbation and prevent readmissions. At this community-based health care system, impressive HF Hospitalist outcomes include decreased length of stay by almost 1 day; decreased 30 day all-cause readmission to an impressive 9%, reduced 30 day HF readmissions to 3.13%, as well as transitioning 13% of patient to hospice care; all while reducing costs during the first 12 months of the HF Hospitalist service.