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: To address this health care priority at UPMC Pinnacle with approximately 1,400 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.
Description: 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. Furthermore, the HF hospitalist team coordinates care with the HF outpatient center. 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.
Conclusions: 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 8.4% (58.4% absolute reduction when compared to non-HF Hospitalist HF admissions as well as national averages), reduced 30 day HF readmissions to 4.31%, as well as high transitioning of patient to hospice care; all while reducing costs during the 3 years (2017-2020) of the HF Hospitalist service.