Emerg­ing Heart Fail­ure Strate­gies Im­prove Out­comes and Re­duce Read­mis­sions

Learn how in­no­va­tive hos­pi­tals lever­age pro­cesses, peo­ple and tech­nol­ogy to bet­ter man­age this com­plex pa­tient pop­u­la­tion and avoid po­ten­tial CMS read­mis­sion penal­ties.

Modern Healthcare - - REGIONAL NEWS - BY EL­IZ­A­BETH HANES, RN

Told by the num­bers, the story of heart fail­ure star­tles even ex­pe­ri­enced health care lead­er­ship. Be­hind the num­bers, of course, are real hu­man be­ings with se­ri­ous med­i­cal con­di­tions. Th­ese pa­tients want and need to avoid hos­pi­tal­iza­tion just as much as their doc­tors and other care providers want to keep them out of the in­pa­tient set­ting. “His­tor­i­cally, heart fail­ure has been one of the least well­man­aged con­di­tions,” said David Laird, CEO of Heart Hos­pi­tal of Austin in Texas. “How­ever, we can change that by pro­vid­ing the high­est qual­ity of clin­i­cal ser­vices and by proac­tively man­ag­ing read­mis­sions.”

That has been eas­ier said than done. “Part of the chal­lenge [in man­ag­ing] heart fail­ure is pre­dict­ing when th­ese pa­tients will end up in the hos­pi­tal,” said Kun­jan Bhatt, MD, direc­tor of heart fail­ure for Austin Heart. “In the past, there has been no good way to an­tic­i­pate changes in pa­tient sta­tus be­fore heart fail­ure symptoms emerge.” And once a pa­tient shows up at the emer­gency room with fluid in the lungs, doc­tors are al­ready play­ing catch-up.

The com­plex­ity and mag­ni­tude of heart fail­ure’s eco­nomic bur­den has also re­sulted in a se­ries of fi­nan­cial re­form pro­grams from the Cen­ters for Medi­care and Med­i­caid Ser­vices (CMS). Th­ese pro­grams, called the Hos­pi­tal Value-Based Pur­chas­ing and Read­mis­sions Re­duc­tion pro­grams, pe­nal­ize and some­times in­cen­tivize fa­cil­i­ties based on bench­marked mor­tal­ity and read­mis­sion rates, as well as a hos­pi­tal’s per-pa­tient costs across 30 days of care. Since heart fail­ure has a high ra­tio of dis­charges per pa­tient (1.26) over a oneyear pe­riod, hos­pi­tals that can­not ef­fec­tively man­age th­ese pa­tients could carry sig­nif­i­cant fi­nan­cial risk.

In this en­vi­ron­ment, tech­nol­ogy part­ners must de­velop ground­break­ing so­lu­tions with health care providers fo­cused on re­duc­ing the need for costly ad­mis­sions and read­mis­sions. St. Jude Med­i­cal (SJM) is one such com­pany that has pi­o­neered in­no­va­tions such as the Quadra™ CRT Sys­tem and Car­dioMEMS™ HF Sys­tem, both of which have demon­strated to dras­ti­cally im­prove clin­i­cal and fi­nan­cial out­comes. 5,6,7,9,10,12

“We un­der­stand that health care providers are look­ing for tech­no­log­i­cal break­throughs that al­low them to bet­ter man­age the com­plex care of pa­tients and lower the cost and risk as­so­ci­ated with treat­ing them,” said Mark Carl­son, MD, Chief Med­i­cal Of­fi­cer of St. Jude Med­i­cal. “We are fo­cused on part­ner­ing with health care providers to search for new ways to meet the grow­ing needs for in­no­va­tive so­lu­tions that truly de­liver value through im­proved care and re­duced costs.”

Across the coun­try, hos­pi­tals and physi­cian groups are putting to­gether new strate­gies that com­bine pro­cesses and peo­ple with emerg­ing tech­nolo­gies to keep heart fail­ure pa­tients healthy. By part­ner­ing with med­i­cal tech­nol­ogy providers and im­ple­ment­ing best prac­tices, health care in­sti­tu­tions can cre­ate heart fail­ure-fo­cused pro­grams that re­duce hos­pi­tal­iza­tions, read­mis­sions and mor­tal­ity—pro­grams that may also help providers avoid Medi­care read­mis­sion penal­ties.

Cre­ate a Heart Fail­ure-Fo­cused Pro­gram

When WVU Health­care in West Vir­ginia be­gan see­ing heart fail­ure read­mis­sion rates around 40% at the 30-day mark, its lead­er­ship de­cided to tackle the is­sue head on. The or­ga­ni­za­tion, which op­er­ates a 531-bed ter­tiary care cen­ter, mounted a re­newed ef­fort to im­prove the man­age­ment of heart fail­ure pa­tients, with goals to stream­line con­ti­nu­ity of care and avoid read­mis­sions by us­ing new med­i­cal tech­nolo­gies. “Keep­ing pa­tient care in mind, we smoothed the tran­si­tion from in­pa­tient to out­pa­tient by as­sign­ing a nurse prac­ti­tioner to be the pa­tient’s pri­mary point of con­tact both dur­ing and af­ter hos­pi­tal­iza­tion,” said Mary Lynne Withrow, direc­tor of WVU Health­care’s car­dio­vas­cu­lar ser­vice line. “The nurse prac­ti­tioner gives clear in­struc­tions and fa­cil­i­tates pa­tient in­ter­ac­tion on an on­go­ing ba­sis. This helps the pa­tient feel con­nected to the care team even af­ter they go home.”

Close com­mu­ni­ca­tion be­tween pa­tients and care­givers fos-

His­tor­i­cally, heart fail­ure has been one of the least well-man­aged con­di­tions. How­ever, we can change that by pro­vid­ing the high­est qual­ity of clin­i­cal ser­vices and by proac­tively man­ag­ing read­mis­sions.

David Laird, CEO // Heart Hos­pi­tal of Austin

ters a strong re­la­tion­ship that can lead to im­proved pa­tient com­pli­ance to the pre­scribed life­style mod­i­fi­ca­tions. Pa­tients of­ten strug­gle to mod­ify their di­ets or quit smok­ing to avoid ex­ac­er­bat­ing their heart fail­ure symptoms. Im­prov­ing con­ti­nu­ity of care can lead to bet­ter com­pli­ance and, in turn, a re­duc­tion in read­mis­sions.

“The strate­gies we put in place re­sulted in a 50% re­duc­tion in 30-day hos­pi­tal read­mis­sion rates. We are now look­ing to new tech­nolo­gies such as pul­monary artery pres­sure mon­i­tor­ing [Car­dioMEMS HF Sys­tem] to help fur­ther re­duce 30-day read­mis­sions go­ing for­ward,” Withrow said.

Heart Hos­pi­tal of Austin ini­ti­ated a sim­i­lar pro­gram in late 2014 that, as a first step, com­bines sup­port­ive care with tech­nol­ogy so­lu­tions to ul­ti­mately im­prove out­comes and re­duce read­mis­sions. “The more a pa­tient is hos­pi­tal­ized, the worse the out­comes,” Bhatt said. “We know that and we have al­ways felt we could do bet­ter at man­ag­ing read­mis­sions.”

Stream­line Process and De­vote Suc­cess­ful Tech­nol­ogy to Your Pro­gram

As health care strat­egy moves to­ward pop­u­la­tion man­age­ment, in­sti­tu­tions that man­age ex­pen­sive dis­eases will need to uti­lize re­sources that im­prove pa­tient health out­comes over the long term. For heart fail­ure pro­grams, that means train­ing and de­vot­ing the proper staff to man­ag­ing the high level of hands-on care th­ese pa­tients re­quire—both in­side and out­side of the care set­ting.

“We’ve found nurs­ing to be one of the most crit­i­cal links in this process [of car­ing for hos­pi­tal­ized heart fail­ure pa­tients],” said Robert Hull, MD, WVU Health­care’s direc­tor of con­ges­tive heart fail­ure. “When nurses have achieved heart fail­ure cer­ti­fi­ca­tion and they’re at the front of the pa­tient care ef­fort, they rep­re­sent highly valu­able team mem­bers as di­rect care­givers and pa­tient ed­u­ca­tors.”

An­other in­te­gral part of any heart fail­ure-fo­cused pro­gram should be the use of the lat­est med­i­cal tech­nol­ogy to de­liver bet­ter pa­tient out­comes while si­mul­ta­ne­ously re­duc­ing costs. Some of to­day’s med­i­cal de­vices can do just that.

Car­diac resyn­chro­niza­tion ther­apy (CRT), for ex­am­ple, has been crit­i­cal to man­ag­ing and even im­prov­ing symptoms of some of the sick­est heart fail­ure pa­tients. Tra­di­tional CRT de­vices lack op­tions in how pac­ing ther­apy is de­liv­ered, which re­sults in com­pli­ca­tions that can lead to sur­gi­cal re­vi­sion or dis­con­tin­u­a­tion of CRT treat­ment. In re­sponse, SJM de­vel­oped and in­tro­duced the Quadra CRT Sys­tem that in­creases pac­ing op­tions for physi­cians. Com­pared with stan­dard bipo­lar pacemaker tech­nol­ogy, this tech­nol­ogy has been shown to lower hos­pi­tal­iza­tion costs by 87% 5, lower hos­pi­tal­iza­tion rates by 53% 6 and achieve an 18% rel­a­tive re­duc­tion in all-cause mor­tal­ity. 7

“Part of bet­ter and more ef­fi­cient care is do­ing things right the first time,” Hull said. “The great thing about the new quadripo­lar pac­ing tech­nol­ogy is it gives you mul­ti­ple com­bi­na­tions to try to get a lead work­ing on the pa­tient’s heart. In my ex­pe­ri­ence, this has re­ally cut the need for ad­di­tional pro­ce­dures to re­po­si­tion the leads.” The ev­i­dence sup­ports this ex­pe­ri­ence. The SJM Quadra Sys­tem alone has been fea­tured in more than 100 pub­li­ca­tions demon­strat­ing im­proved clin­i­cal and eco­nomic out­comes.

Deploy Re­mote Mon­i­tor­ing for Bet­ter Pa­tient Out­comes and Re­duced Read­mis­sion Rates

His­tor­i­cally, pa­tients wound up in the hos­pi­tal with short­ness of breath and other un­pleas­ant symptoms be­fore heart fail­ure treat­ment could be ad­min­is­tered. Even tele­mon­i­tor­ing vi­tal signs such as weight, blood pres­sure and in­tratho­racic im­ped­ance did not re­sult in the proac­tive care nec­es­sary to sig­nifi

cantly re­duce mor­tal­ity or heart fail­ure hos­pi­tal­iza­tions. 11 To­day, in­no­va­tive tech­nol­ogy like the Car­dioMEMS HF sys­tem is break­ing new ground in re­mote pa­tient mon­i­tor­ing as it en­ables physi­cians to man­age heart fail­ure be­fore symptoms de­velop. This is the only avail­able de­vice that re­motely pro­vides clin­i­cians with data on changes in pul­monary artery pres­sure, a pre­cur­sor to the pre­sen­ta­tion of heart fail­ure symptoms. 8 The clin­i­cian can uti­lize the data and di­rect the pa­tient to al­ter med­i­ca­tion or pro­vide other ther­a­peu­tic in­ter­ven­tions, such as di­etary ed­u­ca­tion, with­out re­quir­ing an of­fice visit or hos­pi­tal ad­mis­sion.

The strate­gies we put in place re­sulted in a 50% re­duc­tion in 30-day hos­pi­tal read­mis­sion rates. Mary Lynne Withrow // WVU Health­care

This rep­re­sents a game-changer for heart fail­ure treat­ment as it en­ables proac­tive clin­i­cal de­ci­sions that can avoid hos­pi­tal­iza­tion and im­prove out­comes. In a prospec­tive, ran­dom­ized clin­i­cal study, heart fail­ure hos­pi­tal­iza­tions were re­duced by 37% for pa­tients be­ing mon­i­tored re­motely by the Car­dioMEMS HF Sys­tem. 9 A ret­ro­spec­tive anal­y­sis of the Medi­care pa­tient pop­u­la­tion fur­ther demon­strated a 58% re­duc­tion in all-cause 30-day read­mis­sions for th­ese re­mote mon­i­tored pa­tients. 10 Ad­di­tion­ally, for pa­tients with heart fail­ure and re­duced ejec­tion frac­tion (HFrEF) al­ready on guide­line-di­rected med­i­cal ther­apy, a ret­ro­spec­tive anal­y­sis showed that it re­duced mor­tal­ity by 57%. 12 In re­sponse to data like this, the CMS has deemed the tech­nol­ogy to rep­re­sent a “sub­stan­tial clin­i­cal im­prove­ment” over the cur­rent stan­dard of care and granted both add-on and pass-through pay­ment sta­tus to the de­vice. Even bet­ter, some physi­cians say the tech­nol­ogy fos­ters a closer bond be­tween prac­ti­tioner and pa­tient, which leads to bet­ter com­mu­ni­ca­tion and pa­tient com­pli­ance. “This tech­nol­ogy is the ic­ing on the cake, in terms of tran­sit of care for heart fail­ure,” Hull said. “Now that we have a way to fol­low a num­ber [re­lat­ing to pul­monary artery pres­sure], we can treat the con­di­tion be­fore we ever get to the

stage where fluid de­vel­ops in the lungs.” Of course, th­ese benefits can only be re­al­ized if pa­tients trans­mit the data. Work­ing with a de­vice maker that com­bines re­mote mon­i­tor­ing tech­nol­ogy with best prac­tices in work­flow to ad­dress pa­tient com­pli­ance can greatly im­pact clin­i­cal and fi­nan­cial out­comes. “So many times tech­nol­ogy drives a wedge be­tween care­giver and pa­tient,” WVU Health­care’s Hull said. “The unique thing about [the Car­dioMEMS HF Sys­tem] is it benefits the care process be­cause the care­giver com­mu­ni­cates with the pa­tient when nec­es­sary based on weekly mon­i­tor­ing re­sults. We’ve seen in­creased pa­tient com­pli­ance when us­ing this de­vice.”

Ex­cep­tional Out­comes for Pa­tients and Hos­pi­tals

Hos­pi­tals and physi­cian groups stand at the be­gin­ning of a new era of im­prov­ing heart fail­ure pa­tient out­comes while re­duc­ing costs. To make this tran­si­tion, they must put to­gether heart fail­ure-fo­cused pro­grams, de­vote ad­e­quate re­sources to the pro­gram and part­ner with med­i­cal tech­nol­ogy man­u­fac­tur­ers like SJM that can of­fer a com­pre­hen­sive so­lu­tion. Not only will im­proved care ben­e­fit pa­tients and po­ten­tially ex­tend their lives, but re­duc­ing read­mis­sion rates will fi­nan­cially ben­e­fit sys­tems by help­ing them avoid the Medi­care penal­ties and other costs.

A Mod­ern Health­care Cus­tom Me­dia pub­li­ca­tion

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