1 IHI Expedition: Effective Implementation of Heart Failure Core ProcessesPeg Bradke, RN, MA, Faculty Christine McMullan, MPA, Director November 17, 2011 These presenters have nothing to disclose

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4 Chat Time! What is your goal for participating in this Expedition?

5 Join Passport to: Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements. Train your middle managers to effectively lead quality improvement initiatives. Enhance your strategic planning with customized whole systems data and selected benchmarking information. . . . and much, much more for $5,000 per year! Visit for details. To enroll, call or

6 What is an Expedition? ex•pe•di•tion (noun)1. an excursion, journey, or voyage made for some specific purpose 2. the group of persons engaged in such an activity 3. promptness or speed in accomplishing something

7 Christine McMullan Chris McMullan, MPA, is the Director of Continuous Quality Improvement at Stony Brook University Medical Center. She served as an adjunct faculty member at the Harriman Business School and School of Professional Development at Stony Brook University. She was Lead Faculty on the IHI Early Warning Systems: The Next Level of Rapid Response Expedition and a Faculty member on the IHI Sepsis Detection and Initial Management Expedition. She was a co-faculty member of the Hospital Association of New York State's 2007 learning collaborative to prevent ventilator associated pneumonia. Ms. McMullan has held a variety of managerial positions in quality improvement and human resources.

8 Peg Bradke, RN, MA Peg M. Bradke, RN, MA, Director of Heart Care Services, St. Luke's Hospital, coordinates services for two intensive care units, two step-down telemetry units, the Cardiac Catheter Lab, Electrophysiology Lab, Diagnostic Cardiology, Interventional/Vascular Lab, and Cardiopulmonary Rehabilitation. In her 25-year career, she has had various administrative roles in critical care areas. Ms. Bradke works with the Institute for Healthcare Improvement on the Transforming Care at the Bedside initiative and Transitions Home work. She is President-Elect of the Iowa Organization of Nurse Leaders.

9 Where are you joining from?

10 Ground Rules We learn from one another – “All teach, all learn”Why reinvent the wheel? - Steal shamelessly This is a transparent learning environment All ideas/feedback are welcome and encouraged!

11 Schedule of Calls November 17 12:00 – 1:30 PM ETIntroduction, Objectives, Expedition Overview December 1, 2011, 12 – 1 PM ET Importance of LVS assessment in the reliable recognition of HF December 15, 2011, 12 – 1 PM ET Offering adult smoking cessation advice and counseling January 5, 2012, 12 – 1 PM ET Benefits of providing ACE/ARBs at discharge for HF patients January 19, 2012, 12 – 1 PM ET Anticoagulant at discharge for chronic atrial fibrillation February 2, 2012, 12 – 1 PM ET Discharge instructions and dietary considerations

12 Today’s Agenda Expedition objectives and your survey responsesMedical management for heart failure IHI’s Model for Improvement Overview for increasing reliability with heart failure core processes Homework for next session

13 Expedition ObjectivesTo provide hospitals with highly effective ideas and practices in improving reliability in the treatment of heart failure. The expedition will focus on key elements of care to ensure patients with heart failure have less severe symptoms, better quality of life, and fewer readmissions to the hospital. Conduct left ventricular systolic (LVS) assessment Provide adult smoking cessation advice and counseling Provide ACE inhibitor or angiotensin receptor blockers (ARB) at discharge Provide anticoagulant at discharge for chronic atrial fibrillation Establish discharge instructions

14 Survey Responses Director of Quality, Nurse Practitioner, Registered Nurse, Chart Abstractor and Clinical Nurse Specialist

15 Survey Responses

16 Goal for participationLearn from others Collaborate with others in improving quality To better understand core measure processes Improve heart failure care Prevent readmission

17 How are you identifying patients?Admitting diagnosis Concurrent review H&P medical diagnosis history Elevated BNP levels EMR triggers

18 What are your barriers to reliability?Physician and nurse lack of understanding of core measures MD and RN collaboration on discharge instructions/medication reconciliation Electronic health record – both pro and con Inability to identify HF patients on admission

19 Last Quarter Composite Score

20 William E. Lawson, M.D., FACCP, FACC, FSCAIDr. William Lawson graduated from Rutgers Medical School in Dr. Lawson has been at SUNY, Stony Brook since 1980, where he is currently Professor of Medicine in the Division of Cardiology. At Stony Brook he has acted as Chief of Cardiology, Director of Echocardiography, Non-Invasive, Invasive, and Preventive Cardiology. He is currently Director of Cardiac Outcomes Research and Preventive Cardiology. Dr. Lawson is a practicing interventional cardiologist and Director of the Interventional Cardiology fellowship program at Stony Brook. Dr. Lawson is ABIM certified in Internal Medicine, Cardiovascular Disease, Interventional Cardiology, Advanced Heart Failure & Transplant Cardiology and is a Fellow of the ACC, ACCP, SCAI, ACA. He has broad expertise and interest in the field of cardiovascular disease and is actively involved in the teaching and mentoring of physicians and allied health care professionals at SUNY, Stony Brook.

21 William E. Lawson, M.D., FACCP, FACC, FSCAI Stony Brook HospitalCONGESTIVE HEART FAILURE William E. Lawson, M.D., FACCP, FACC, FSCAI Stony Brook Hospital

22 Heart Failure: A Growing BurdenPrevalence is increasing: Aging populations, HBP, DM, MI survivors. Overall rate is 3-20/1,000. Rate over age 65 is /1,000. One –year mortality rates are 35-45% in newly diagnosed cases. Heart failure is the most frequent cause of hospitalization over age 65.

23 Symptoms Fatigue, easy tiringDyspnea, Dyspnea on exertion, Paroxysmal nocturnal dyspnea Edema Persistent cough/ wheezing Palpitations, presyncope

25 New Classification of Heart FailureStage Patient Description A High risk of developing heart failure (HF) Hypertension CAD Diabetes mellitus Family history of cardiomyopathy B Asymptomatic LVD Previous MI LV systolic dysfunction Asymptomatic valvular disease C Symptomatic LVD Known structural heart disease Shortness of breath and fatigue Reduced exercise tolerance D Refractory end-stage HF Marked symptoms at rest despite maximal medical therapy (eg, those who are recurrently hospitalized or cannot be safely discharged from the hospital without specialized interventions) Hunt SA et al. J Am Coll Cardiol. 2001;38:

26 HF Risk Factor Treatment GoalsHypertension Generally < 130/80 Diabetes See ADA guidelines1 Hyperlipidemia See NCEP guidelines2 Inactivity 20-30 min. aerobic 3-5 x wk. Obesity Weight reduction < 30 BMI Alcohol Men ≤ 2 drinks/day, women ≤ 1 Smoking Cessation Dietary Sodium Maximum 2-3 g/day 1Diabetes Care 2006; 29: S4-S42 2JAMA 2001; 285: The June 2006 AHA guide regarding exercise, “Making healthy food and lifestyle choices: Our guide for American adults,” recommends 30 minutes or more of aerobic exercise every day. The recommendations and a free brochure are available at or AHA-USA1. Adapted from:

27 Treating Hypertension to Prevent HFAggressive blood pressure control: Aggressive BP control in patients with prior MI: Decreases risk of new HF by ~ 50% 56% in DM2 Decreases risk of new HF by ~ 80% Data come primarily from SHEP study. Data regarding type 2 diabetes come from UKPDS study. Lancet 1991;338: (STOP-Hypertension JAMA 1997;278:212-6 (SHEP) UKPDS Group. UKPDS 38. BMJ 1998;317:

28 After a 2 year visit to the US, Michelangelo’s David is returning to ItalySponsored by

29 Prevention—ACEI and Beta BlockersACE inhibitors are recommended for prevention of HF in patients at high risk for this syndrome, including those with: Coronary artery disease Peripheral vascular disease Stroke Diabetes and another major risk factor Strength of Evidence = A ACE inhibitors and beta blockers are recommended for all patients with prior MI Strength of Evidence = A

30 Management of Patients with Known Atherosclerotic Disease But No HFPlacebo HOPE Treatment with ACE inhibitors decreases the risk of CV death, MI, stroke, or cardiac arrest. NEJM 2000;342: (HOPE) Lancet 2003;362:782-8 (EUROPA) Ramipril 22% rel. risk red. p < .001 EUROPA Placebo In the HOPE study, relative risk of the composite outcome of MI, stroke, or death from CV causes in the ramipril group as compared with the placebo group was 0.78 at five years. In EUROPA the relative risk reduction of CV death, MI, or cardiac arrest was 20%. Perindopril 20% rel. risk red. p = .0003

31 CAD; Leading Cause of Heart FailurePost MI survivors Magnitude of initial infarct, cumulative damage, adverse remodeling all play roles Chronic ischemia and LV dysfunction Prolonged ischemia causes hibernation, stunning Shorter periods of ischemia result in reversible myocardial dysfunction

32 Angioplasty Pre PCI Post PCI

33 The Evolving Model of Heart Failure TreatmentCardiorenal Hemodynamic Neurohumoral Digitalis and Inotropes and Modification of diurtics improve vasodilators activation of cardiac and improve LV adrenergic, renal function performance RAAS systems

34 Treatment of Post-MI Patients with Asymptomatic LV Dysfunction (LVEF ≤ 40%)SAVE Study All-cause mortality ↓19% CV mortality ↓21% HF development ↓37% Recurrent MI ↓25% Mortality Rate Placebo Captopril 19% rel. risk reduction p = 0.019 Years Pfeffer et al. NEJM 1992;327:669-77

35 Added Value of BB Post-MIBeta blocker (carvedilol) benefit post-MI with LVEF ≤ 40%, receiving usual therapy [revascularization, anticoagulants, ASA, and ACEI]. Capricorn trial All-cause mortality reduced (HR = 0.077; p = 0.03) Cardiovascular mortality reduced (HR = 0.75; p = .024) Recurrent non-fatal MIs reduced (HR =.59; p = .014) There was no difference between the carvedilol and placebo groups in the primary endpoint of all-cause mortality or hospital admission for cardiovascular problems (HR = .92 ; CI = ). Dargie HJ. Lancet 2001;357:

36 Causes of Dyspnea

37 Therapy: ACE InhibitorsACE inhibitors are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40% Strength of Evidence = A ACE inhibitors should be titrated to doses used in clinical trials (as tolerated during uptitration of other medications, such as beta blockers) Strength of Evidence = C ACE inhibitors are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Adapted from:

38 ACE Inhibitors in Heart Failure: From Asymptomatic LVD to Severe HFSOLVD Prevention (Asymptomatic LVD) 20% death or HF hosp. 29% death or new HF CONSENSUS (Severe Heart Failure) 40% mortality at 6 mos. 31% mortality at 1 year 27% mortality at end of study No difference in incidence of sudden cardiac death SOLVD Treatment (Chronic Heart Failure) SOLVD Prevention also showed a 37% reduction in the development of new HF and a 44% reduction in multiple hospitalizations for HF. The patients in SOLVD Treatment had an LVEF < 35%. Largest reduction in deaths were among those attributed to progressive HF. There was also a 26% reduction among those who died or were hospitalized due to worsening HF. Reduced mortality in CONSENSUS due to impact on progression of disease severity, rather than on sudden cardiac death.. 16% mortality SOLVD Investigators. N Engl J Med 1992;327:685-91 SOLVD Investigators. N Engl J Med 1991;325: CONSENSUS Study Trial Group. N Engl J Med 1987;316:

39 Therapy: Beta BlockersBeta blockers shown to be effective in clinical trials are recommended for symptomatic and asymptomatic patients with an LVEF ≤ 40%. Strength of Evidence = A Beta blockers are recommended as routine therapy for asymptomatic patients with an LVEF ≤ 40%. Post MI Strength of Evidence = B Non Post-MI Strength of Evidence = C Beta blockers shown to be effective in clinical trials include carvedilol, bisoprolol, and metoprolol succinate. See slide 17.

40 Carvedilol Predischarge Initiation Postdischarge Initiation*IMPACT-HF Primary End Point: Patients Receiving Beta Blocker at 60 Days Improvement 18% Initiation of a beta blocker prior to hospital discharge is safe and well tolerated in the majority of patients and dramatically improves utilization of this evidence-based therapy following discharge. Carvedilol Predischarge Initiation (n=185) Physician Discretion Postdischarge Initiation* (n=178) Gattis WA et al. JACC 2004;43:

41 Therapy: Angiotensin Receptor BlockersARBs are recommended for routine administration to symptomatic and asymptomatic patients with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency. Strength of Evidence = A

42 ARBS in Patients Not Taking ACE Inhibitors: Val-HeFT & CHARM-AlternativePlacebo Survival % Valsartan CV Death or HF Hosp % Placebo Candesartan The Val-HeFT paper cited here is a sub-group analysis of study participants not on an ACE inhibitor (N=366); they were not defined as ACE-intolerant. This table shows a reduction in all-cause mortality from 27.1% in the placebo group to 17.3% in the group treated with valsartan. CHARM-Alternative enrolled 2028 patients not receiving ACEI due to previous intolerance. Primary outcome was composite of cardiovascular death or hospital admission for HF. At median follow up of 33.7 months, 33% of the patients in the candesartan group and 40% of the patients in the placebo group had CV death or HF hospitalization p = 0.017 HR 0.77, p = Months Months Maggioni AP et al. JACC 2002;40:1422-4 Granger CB et al. Lancet 2003;362:772-6

43 Therapy: Aldosterone AntagonistsAn aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have: NYHA class III or IV HF from reduced LVEF (≤ 35%) One should be considered in patients post-MI with clinical HF or diabetes and an LVEF < 40% who are on standard therapy, including an ACE inhibitor (or ARB) and a beta blocker. Renal function issues on next slide. Strength of Evidence = A Adapted from:

44 Aldosterone Antagonists in HFEPHESUS (Post-MI) RALES (Advanced HF) Eplerenone Probability of Survival Spironolactone Placebo Placebo RR = 0.70 P < 0.001 RR = 0.85 P < 0.008 Months Pitt B. N Engl J Med 1999;341:709-17 Pitt B. N Engl J Med 2003;348:

45 Therapy: Hydralazine and Oral NitratesA combination of hydralazine and isosorbide dinitrate is recommended as part of standard therapy, in addition to beta-blockers and ACE-inhibitors, for African Americans with HF and reduced LVEF: NYHA III or IV HF Strength of Evidence = A NYHA II HF Strength of Evidence = B This represents one of the key differences between the HFSA guideline and the AHA/ACC guideline, since this is a stronger recommendation for HDZN/ISDN.

46 A-HeFT All-Cause Mortality43% Decrease in Mortality Survival % Fixed Dose ISDN/HDZN Placebo P = 0.01 Days Since Baseline Visit Taylor AL et al. N Engl J Med 2004;351:

47 Therapy: Diuretics Diuretic therapy is recommended to restore and maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by: Congestive symptoms Signs of elevated filling pressures Strength of Evidence = A Loop diuretics rather than thiazide-type diuretics are typically necessary to restore normal volume status in patients with HF Strength of Evidence = B Congestive symptoms include orthopnea, edema, and shortness of breath. Signs of elevating filling pressures include jugular venous distention, peripheral edema, pulsatile hepatomegaly, and, less commonly, rales.

48 Treatment by Heart Failure StageStage A Stage B Stage C Stage D Treat HBP All Stage A All Stage A All Stage A, Stop smoking measures measures B,C measures Treat lipids ACEI in post ACEI LVAD Exercise MI, reduced Diuretics Ht Transplant No ETOH LVEF BB Continuous No Drugs BB in post MI, Digitalis IV inotropes ACEI in DM, reduced LVEF Spironolactone HBP, Vascular in Class III,IV Disease

49 Device Therapy: Prophylactic ICD PlacementProphylactic ICD placement should be considered in patients with an LVEF ≤35% and mild to moderate HF symptoms: Ischemic etiology Strength of Evidence = A Non-ischemic etiology Strength of Evidence = B In patients who are undergoing implantation of a biventricular pacing device, use of a device that provides defibrillation should be considered Strength of Evidence = B Decisions should be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions, ideally after 3-6 mos. of optimal medical therapy Strength of Evidence = C Before placement, LV function should be re-assessed, ideally after 3-6 months of optimal medical therapy. Adapted from:

50 MADIT II: Prophylactic ICD in Ischemic LVD (LVEF 30%)65 (.69) 170 (.78) 329 (.90) 490 Conventional 9 110 (.78) 274 (.84) 503 (.91) 742 Defibrillator Number at Risk 1 2 .7 .8 .9 1.0 Probability of Survival Therapy Year .6 4 Moss AJ et al. N Engl J Med 2002;346:877-83

51 Resynchronization Two leads allow pacing of the right atrium and ventricle. The third lead is advanced through the coronary sinus into a venous branch along the lateral wall of the left ventricle, allowing early activation of the left ventricle.

52 Device Therapy: Biventricular PacingBiventricular pacing therapy is recommended for patients with all of the following: Sinus rhythm A widened QRS interval (≥120 ms) Severe LV systolic dysfunction (LVEF < 35%) Persistent, moderate-to-severe HF (NYHA III) despite optimal medical therapy Strength of Evidence = A This represents another difference between the HFSA guideline and the AHA/ACC’s in that this is not as strong a recommendation.

53 CRT Improves Quality of Life and NYHA Functional Class(%) *P<.05 Abraham WT et al. Circulation 2003;108:

54 CRT in Patients with Advanced HF and a Prolonged QRS Interval: COMPANIONPrimary End Point: All-Cause Mortality Death or Hospitalization Due to HF Patients in the study group had advanced HF and a QRS interval of at least 120. There were three treatment arms: (1) optimal pharmacologic therapy (OPT) (2) OPT plus CRT (3) OPT-CRT plus an ICD Risk of all-cause mortality reduced by 19% in group with CRT and ICD (p =.014) Risk of death or hospitalization from HF reduced by 34% in ICD group and by 40% in ICD-CRT group (p < .001) Bristow MR et al. N Engl J Med 2004;350:

55 Effect of CRT Without an ICD on All-Cause Mortality: CARE-HF5 71 192 321 365 404 Medical Therapy 8 89 213 351 376 409 CRT Number at risk 500 1,000 1,500 25 50 75 100 % Event-Free Survival Medical Therapy Days HR = 0.64 (95% CI = ) p = .0019 Cleland JG et al. N Engl J Med 2005;352:

56 Treatment Options: Acute Decompensated HFFluid and sodium restriction Diuretics, especially loop diuretics Ultrafiltration/renal replacement therapy (in selected patients only) Parenteral vasodilators (nitroglycerin, nitroprusside, nesiritide) Inotropes (milrinone or dobutamine)

57 Clinical Presentation of Acute Decompensated Heart FailureClincal Evaluation of Acute Decompensated Heart Failure

58 Impact of Education on ComplianceNonadherence rate when patients . . . Recall MD advice Don’t recall advice Medications 8.7% 66.7% Diet 23.6% 55.8% Activity 76.4% 84.5% Smoking 60.0% 90.4% Alcohol 81.8% Potential improvement with medication compliance alone would have monumental economic and health impact. Shows importance of institutional compliance with “patient education before discharge” HF performance measure. Kravitz et al. Arch Int Med 1993;153:

59 Evidence-Based Treatment Across the Continuum of Systolic LVD and HFControl Volume Improve Clinical Outcomes Diuretics Digoxin -Blocker ACEI or ARB Aldosterone Antagonist or ARB Treat Residual Symptoms ±CRT & ICD Hydralazine/Isosorbide dinitrate Clinical outcomes include reduced mortality, HF hospitalizations, and progressive LV remodeling.

60 ? The Future: Angiogenesis/ Myogenesis via Cell Transplants

61

62 Questions? Raise your hand Use the Chat

63 Measurement of ImprovementWhat are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Act Plan Study Do Aim of Improvement Measurement of Improvement Developing a Change When you combine the 3 questions with the PDSA cycle—you get the MFI Use it in the community as the change model to provide structure to improvement activities—the model is action learning as to what works/fails in small, iterative cycles of testing Testing a Change Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco, CA: Jossey-Bass, 1996.

64 Plan Do Study Act Compose aim Pose questions/predictionsCreate action plan to carry out cycle (who, what, when, where) Plan for data collection Do Study Act Carry out the test and collect data Document what occurred Begin analysis of data Complete data analysis Compare to predictions Summarize learning Decide changes to make Arrange next cycle

65 Principles & Guidelines for TestingA test of change should answer a specific question A test of change requires a theory and prediction Test on a small scale Collect data over time Build knowledge sequentially with multiple PDSA cycles for each change idea Include a wide range of conditions in the sequence of tests

66 Repeated Use of the PDSA CycleChanges That Result in Improvement Sequential building of knowledge under a wide range of conditions A P S D Spread DATA D S P A Implementation of Change A P S D Wide-Scale Tests of Change Hunches Theories Ideas A P S D Follow-up Tests Very Small Scale Test

67 Aim: Implement Rapid Response Team on non-ICU unitImproved Communication D S P A Cycle 6: Expand rounds to one unit for one shift seven days a week A P S D DATA D S P A Cycle 5: Have Nurse Practitioner respond to calls in addition to RT and RN A P S D A P S D Cycle 4: Expand coverage of RRT on unit to one unit for one shift for five days Cycle 3: Have Respiratory Therapist attend rapid response calls with ICU Nurse Cycle 2: Repeat cycle 1 for three days Cycle 1: ICU nurse responds to rapid response team calls on one unit, one shift for one day 67

68 Questions? Raise your hand Use the Chat

69 IHI Heart Failure ExpeditionIHI Expedition 2011 Peg M. Bradke, RN, MA St. Luke’s Hospital, Cedar Rapids, Iowa

70 Heart Failure Core MeasuresHF1 – Discharge Instructions HF 2 – Evaluation of LVS Function HF 3 – AEI or ARB for LVSD HF 4 – Adult Smoking Cessation Advice/Counseling

71 What are the drivers? Doing the Right thing with Evidenced Based Care for our Patients Meeting requirements for Valued Based Purchasing Marketing –Consumer Access to Hospital Compare.gov Reducing Our Potential Avoidable Readmissions

72 Doing the Right thing The right care for every patient, every timeIs any defect acceptable To us as a health care system? To you as a health care professional? To anyone expecting the care we would want our loved ones to receive? Which would you be okay with your loved not getting?

73 Legislative Requirements for VBPMultiple Requirements Legislation requires that the FY 2013 Hospital VBP program apply to payments for discharge occurring on or after Oct. 2012 Hospital VBP measures must be included on Hospital Compare website Under proposal, measures could be added to Hospital VBP if measures have been displayed on Hospital Compare for one year

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75 HQA Recent Report for HF10%of all Hospital National Performance Submitting equal to or better than 100% HF 1-discharge % 90% HF 2- LV function 100% 98% HF 3- ACE/ARB 100% 95% HF 4- Smoking Cessation 100% 97%

76 “The Billion Dollar U-Turn”17.6% of all Medicare admissions are readmissions within 30 days Accounting for $15 B in spending Not all re-hospitalizations are avoidable, but many are 13.3% of all Medicare admissions; 76% potentially avoidable Accounts for $12B in Medicare spending Heart Failure, Pneumonia, COPD, Acute MI lead the medical conditions CABG, PTCA, other vascular procedures lead the surgical conditions Disparities exist along racial and “burden of illness” lines There is wide intra-state and inter-state variation Medicare 30-day readmission rate varies 13-24% by state Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008 MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007 Commonwealth Fund State Scorecard on Health System Performance. June 2007

77 STAAR Initiative: Two Concurrent StrategiesProvide technical assistance to front-line teams of providers working to improve the transition out of the hospital and into the next care setting Actively engage hospitals and their community partners in co-designing processes to improve transitions Provide coaching by content experts and facilitate collaborative learning with the goals of creating exemplary cross continuum models in each state and identifying high-leverage changes in each care setting Develop quality improvement expertise and content experts to mentor others Create and support state-based, multi-stakeholder initiatives to concurrently examine and address the systemic barriers to improving care transitions, care coordination over time. State leadership, steering committees, key allies, aligning initiatives Technical assistance to “staff” challenges in framing the issue, designing strategy, scanning for developments in best practice/policy Specific focus areas: understanding the financial impact of success, aligning payment to support high leverage interventions, developing state rehospitalization data reports

78 Transition from Hospital to HomeEnhanced Assessment Teaching and Learning Real-time Handover Communications Follow-up Care Arranged Post-Acute Care Activated MD Follow-up Visit Home Health Care (as needed) Social Services (as needed) Skilled Nursing Facility Services Alternative or Supplemental Care for High-Risk Patients * Hospice/Palliative Care Transitional Care Models Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare) IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated? * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

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80 Creating an Ideal Transition HomePerform Enhanced Admission Assessment of Post-Hospital Needs Involve the patient, family caregivers and community providers as full partners in completing a needs assessment of the patient home going needs Reconcile medications C. Identify the patient’s initial risk of readmission Create a customized discharge plan based on the assessment. Provide Effective Teaching and Facilitate Enhanced Learning Involve all learner in patient education Redesign patient education process Redesign patient teaching print materials Use Teachback regularly throughout the hospital stay III. Ensure Post-Hospital Care Follow-Up Reassess the patient’s medical and social risk for readmission. Prior to discharge: Schedule timely follow-up care and Initiate clinical and social services summarized from the assessment of post-hospital needs. Provide Real-Time Handover Communication Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list. Provide customized, real-time critical information to next clinical care provider(s). For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care provider(s) to discuss the patient’s status and plan of care. 80

81 Analysis of Results-to-DateReducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time Improving transitions in care requires co-design of transitional care processes among “senders and receivers” Providing intensive care management services for targeted high risk patients is critical Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months

82 Other Resources BOOST Hospital to Home H2H (ACC/IHI) Project REDToolkit –Medication Reconciliation, Treatment plan, discharge summary communication Hospital to Home H2H (ACC/IHI) Virtual Learning Community and H2H website Project RED Reconciling the discharge plan with national guidelines and critical pathways when relevant – CMS discharge list

83 Building Reliability Need Reliability of the Evidenced Based Core measures to build on the continuum of care after discharge Core Measures work in tandem with Readmission Effort First step identifying the Core Measure Patients

84 Who identifies the HF Core Measure PatientsFrontline Staff vs. dedicated individual Frontline staff needs to understand the measures and the context of the work All departments must take ownership to manage the process Role of Nursing Unit Leadership and Senior Leadership

85 How do you identify the HF Core Measure Patient?BNP: ß-type Natriuretic Peptide Hormone released into the blood in response to increased heart pressure or overload Circulating BNP has an inverse relationship to degree of cardiac dysfunction (the higher the BNP, the lower the ejection-fraction and the higher New York Heart Association Level) IV Lasix/Diuretic Report

86 Follow Up in EMR Verify the patient has HF through chart review and daily rounds Patient has symptoms of HF Physician notes that patient exhibits symptoms of HF Note if patient has previous history of HF

87 Is Your Approach “Real Time”Reviewing Concurrently with concurrent chart abstraction Literature reports the results of core measures improved significantly. These methods prove to be efficient and cost effective as les time was required when compared to retrospective chart review and more current data were available to anaylze and act upon. Advantages include just in time one to one education of staff, optimizing evidenced based patient care opportunities and documentation, and responding to staff questions.

88 Documentation Documentation is a key driverAccurate and complete to meet measure definitions Impact on coding Patient Safety Maximize Reimbursements

89 Results Retrospective of Chart ReviewSix patients did not have proper discharge instructions: Two patients had cancer – documentation of chemo-induced heart failure One patient with admitting diagnosis of allergic reaction One patient ICD implant Remaining two were heart failure diagnoses that were missed

90 Core Measure Discharge Tools or ChecklistsAre you using a Discharge Checklist to assess compliance during the hospitalization and then at the time of discharge with national guidelines for care of HF patient Please share you tools/checklist or processes over the time of this expeditions.

91 HF – 1 Discharge InstructionNumerator: Heart Failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following: Activity level Diet Discharge Medications Follow up appointment Weight Monitoring What to do if symptoms worsen Denominator: Heart failure patients discharged home

92 HF Discharge InstructionsUse pre-printed heart failure discharge instructions on the following patients: newly diagnosed or history of heart failure patients that we are currently treating for HF; history of ischemic cardiomyopathy or LVEF <40; patients currently hospitalized to have Bi-V or ICD implant who have a history of CHF or LVEF <40%. CHF Discharge Instructions

93 PATIENT EDUCATION YOU ARE THE PATIENT’S LIFELINE FOR INFORMATION!Give in small doses Use their terms Be empathetic but emphatic! Ask specific questions to determine their knowledge level (how much sodium/how much weight to report/when to weigh, etc.)

94 Medication ReconciliationHome Medication List Hospital Medication List Discharge Instructions Physician’s Discharge Summary ALL MUST MATCH EXACTLY!! Many errors around lack of medication reconciliation at discharge

95 Medication Reconciliation cont.Includes - All prescribed medications All over the counter medications All PRN medications Medication name, dosage and route Same rules apply for Long term or skilled care facilities

96 Medication Reconciliation cont.What is your check process for your providers and staff? Do you do a discharge time out? Do you do a double check by two independent reviewers? Is a Pharmacist involved? How do you assure all medications are addressed? How do you assure required discharged medications are addressed?

97 HF 2- Evaluation of LVS FunctionNumerator: Heart failure patients with documentation in the hospital record that LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. Denominator: Heart failure patients

98 EF Amount of blood pumped out of the heart with each contractionNormal = 50 – 70% Abnormal in CMS world = <40%

99 HF 3 – ACEI or ARB for LVSD Numerator: Heart Failure patients who are prescribed an ACEI or ARB at hospital discharge Denominator: Heart failure patients with LVSD

100 Contraindications CMS updates the measures twice a year – the contraindications frequently are areas that are changed. Don’t worry about specific contraindications. Just encourage the Providers to document any contraindications (i.e. CHF & Acute Beta Blockers or Coumadin and Acute ASA)

101 HF 4 – Adult Smoking Cessation Advice/CounselingNumerator: Heart failure patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay Denominator: Heart failure patients with a history of smoking cigarettes any time during the year prior to hospital arrival

102 SMOKING ALL PATIENTS regardless of diagnosis, need documentation of smoking education (cessation education, stay quit or second hand smoke exposure). If unable to give this to the patient, it can be given to the family. If unable to give education at the time the initial nursing history/assessment is completed and documented, smoking education cessation should be documented when the patient is able to receive the information

103 HF BEST PRACTICE LVEF Assessment – preferably within the past two years Smoking cessation education for current smokers and those who have smoked in the past 12 months ACE Inhibitor or ARB prescribed at discharge for patients with LVEF of less than 40% (if ACE or ARB is not used the physician needs to document the reason for both) Preprinted CHF Discharge Instructions Utilized – to cover key CHF information including weight monitoring, medications, diet, what to do if symptoms worsen, activity and follow-up

104 Make your process sustainable over timeContinually manage the process using the PDSA cycle Keep your eye focused on enhancing the process rather than blaming someone or some group for failure Key to work: culture change, communication and teamwork Let’s use this expedition to share our best practices and learn from each other.

105 Homework for Next Call What has been your experience in concurrent data abstraction for core measures as opposed to retrospective? Do you have results that demonstrate improved efficiency and/or results for a given method? Be prepared to discuss your findings for advantages/or disadvantages for the method you are utilizing.

106 Expedition CommunicationsIf you would like additional people to receive session notifications please send their addresses to We have set up a listserv for the Expedition to enable you to share your progress. To use the listserv, address an to

107 Next Session December 1, 2011, 12 – 1 PM ET Importance of LVS assessment in the reliable recognition of HF