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©2016 The Advisory Board Company • advisory.com

Cardiovascular Roundtable

Reducing Cardiovascular Procedural Readmissions

The CV leader’s playbook for preventing unnecessary procedural readmissions

©2016 The Advisory Board Company • 32165 advisory.com2

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Megan Tooley

Julie Bass, MPH

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Dana Khan, MPH

Sruti Nataraja

Executive DirectorBrian Contos


Table of Contents

Additional Implementation Resources

Please see the online Appendix for additional resources to support implementing strategies in this publication, including:

• Risk stratification tools

• Cross-continuum CV care pathways

• Patient education materials

These resources and more are available at: advisory.com/cr/proceduralreadmissionstoolkit

Advisors to Our Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Introduction: CV Procedural Readmissions in the Spotlight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

I. Special Report: Build a Foundation for CV Procedural Excellence . . . . . . . . . . . . . . . . . . . . . 17

Data-Driven Performance Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

High-Caliber Procedural Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Appropriate Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

II. Perfect Inpatient Care to Improve Long-Term Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Lesson 1: Reduce Risk of Post-Procedure Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Lesson 2: Coordinate Care Across Patient Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

III. Ensure Effective Post-Discharge Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Lesson 3: Enable Patients to Self-Manage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Lesson 4: Optimize the Transitional Care Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Lesson 5: Maximize High-Risk Transition Clinics for Procedural Patients . . . . . . . . . . . . . . . . . . 77

IV. Optimize Longitudinal Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Lesson 6: Ensure Appropriate Cardiac Rehab Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Lesson 7: Coordinate with Providers Delivering Ongoing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Lesson 8: Prevent Unnecessary Admission from the ED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Coda: Expand the Ambition for Longitudinal CV Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109


Advisors to Our Work

The Cardiovascular Roundtable is grateful to the organizations that shared their insights, analysis,

and time with us. We would especially like to recognize the following institutions for being particularly

generous with their time and expertise.

With Sincere Appreciation

Atlantic HealthMorristown, NJ

Aurora Health CareMilwaukee, WI

Baptist Health South FloridaMiami, FL

Baystate Medical CenterSpringfield, MA

Billings ClinicBillings, MT

Bronson Methodist HospitalKalamazoo, MI

Carolinas HealthCare Charlotte, NC

Central Maine HealthcareLewiston, ME

Christiana Care Health SystemWilmington, DE

Gundersen Health SystemLa Crosse, WI

Huntington Memorial HospitalPasadena, CA

Lake HealthConcord, OH

Lancaster General HospitalLancaster, PA

Los Robles Regional Medical CenterThousand Oaks, CA

Massachusetts General HospitalBoston, MA

Memorial Health Care SystemChattanooga, TN

Meridian HealthNeptune, NJ

Montefiore Medical CenterBronx, NY

Nebraska Methodist HospitalOmaha, NE

New Hanover Regional Medical CenterWilmington, NC

Ohio State University Wexner Medical CenterColumbus, OH

Penn MedicinePhiladelphia, PA

Providence Health & ServicesBurbank, CA

SCL HealthDenver, CO

St. Alphonsus Regional Medical CenterBoise, ID

St. Francis HospitalRoslyn, NY

St. Luke’s The WoodlandsThe Woodlands, TX

Tenet Healthcare Florida RegionFort Lauderdale, FL

UC Davis Medical CenterSacramento, CA

UCLA HealthLos Angeles, CA

UMass Memorial HealthcareWorcester, MA

University of Vermont Medical CenterBurlington, VT

Yuma Regional Medical CenterYuma, AZ


Lessons to Reduce CV Procedural Readmissions

Executive Summary

Build a Foundation for CV Procedural Excellence

1. A procedural readmission reduction strategy must begin with ensuring high-quality procedures. Programs need a strong infrastructure for consistently performing excellent procedures to succeed on any quality metrics, including readmissions.

2. Data-driven performance improvement, an experienced and cohesive multidisciplinary procedural team, and appropriate patient selection are fundamental pillars of high-quality procedural programs. Programs that effectively apply this framework will be better poised to implement cross-continuum readmissions reduction strategies.

Perfect Inpatient Care to Improve Long-Term Outcomes

3. Optimize care protocols to mitigate risk of post-procedure complications and infections. As complications and infections drive the majority of procedural readmissions, it is critical to identify patients at high-risk of complication and adjust their pre-, intra-, and post-procedure care accordingly.

4. Implement strategies to enhance coordination across the entire care team throughout the patient’s recovery. Given the number of providers and units procedural patients encounter throughout their stay, there is greater opportunity for care plan miscommunication or loss of data. Strategies such as multidisciplinary rounds, early discharge planning, bedside handoffs, and universal bed units can support care coordination.

Ensure Effective Post-Discharge Transitions

5. Expand your transitional care strategies to accommodate procedural patients. While heart failure transitional care has become a key focus for programs, most are still largely mired in an acute mind-set for procedures. Procedural patients are also particularly vulnerable during the initial transition between the hospital and first physician visit.

6. When building a transitional care strategy, begin with the patients themselves by improving their engagement and ability to self-manage. Transitional care strategies will be in vain if the patient isn’t willing and able to self-manage once he leaves the hospital. Empower patients to manage their recovery through appropriate patient education and discharge instructions patients can understand.

7. Develop transitional care teams to support high-risk patients immediately post-discharge. While the strategies they utilize will be similar to those for medical patients, provide targeted training to enable them to effectively support nuanced post-procedure care needs.

8. Multidisciplinary, high-risk transition clinics can be adapted to manage highest-risk procedural patients to reduce readmissions. Effective clinics collocate staff and resources that manage both the clinical and psychosocial needs of high-risk medical and procedural patients.

Optimize Longitudinal Care Management

9. Cardiac rehab is a proven yet underutilized strategy for reducing readmissions. To increase utilization, hardwire physician referrals and educate patients on the importance of attending.

10. Regardless of where a patient receives ongoing care, non-CV providers require additional support to manage the complex longitudinal needs of procedural patients. CV-specific training, streamlined access to CV support, and cross-continuum care pathways will enhance the care these patients receive

11. Enable ED clinicians to effectively and efficiently triage CV patients to the appropriate level of care to reduce unneeded readmissions. Despite best efforts, there will inevitably be cases where procedural patients return to the ED post-discharge. Often, these patients can be effectively managed in observation or as outpatients if ED physicians are given the right tools.



CV Procedural Readmissions in the Spotlight

Introduction


Source: Rau J, “Medicare Fines 2,610 Hospitals in Third Round of Readmission Penalties,” KHN, October 2, 2014, www.khn.org; Cardiovascular Roundtable research and analysis.

1) Hospital Readmissions Reduction Program.2) Patient Protection and Affordable Care Act.3) Heart failure.4) Acute myocardial infarction.5) Chronic obstructive pulmonary disease.6) Total hip arthroplasty/total knee arthroplasty.7) Coronary artery bypass graft. 8) Penalty applies to all Medicare payments.

Across the past several years, readmissions reduction has become a priority for health care providers, largely due to CMS’s Hospital Readmission Reduction Program (HRRP) implemented as part of the Affordable Care Act in 2010.

This program—now well-known to all hospital leaders—penalizes hospitals with excessive 30-day readmissions for a set of conditions. The first year of penalties went into effect in 2013 for heart failure, AMI, and pneumonia. Since then, the program has expanded both in conditions and penalty amount, which is now up to a 3% reduction in all inpatient Medicare payments.

However, despite best efforts from institutions across the country, readmissions still remain a challenge. In fact, 77% of eligible hospitals were penalized in the fourth year of the HRRP. Additionally, in FY 2016 the average penalty was 0.61%—a penalty on total inpatient Medicare payment, not just payments for included conditions. For example, a hospital with $100M in Medicare revenue would be fined $610,000.

Given the potential financial implications, readmissions remain a concern for many programs.

Readmissions Not a New Priority for CV Programs

Despite Best Efforts, Readmissions Still a Challenge

Hospital Readmissions Reduction Program (HRRP)

June 2007

MedPAC Report to Congress recommends a payment policy to incentivize readmission reduction

March 2010

HRRP1 enacted as part of the PPACA2

October 2012

First year of HRRP penalties for HF3, AMI4, pneumonia;1% of reimbursement at risk

October 2013

Maximum penalty increases to 2%

October 2014

HRRP expands to COPD5, THA/TKA6; maximum penalty increases to 3%

• Mandatory Medicare pay-for-performance program implemented by the PPACA

• Penalizes hospitals for excessive risk-adjusted 30-day readmissions—as compared to expected national average performance—for a set of conditions

• Poor performance for any of the conditions results in a financial penalty, which is a maximum 3% reduction in all Medicare inpatient payments

Hospital Readmissions Reduction Program Has Driven National Focus

77%Percentage of Eligible Hospitals Penalized in Fourth Year of the HRRP (FY 2016)

Majority of Hospitals Still Face Penalties

2,213$277M

0.42%2,225 $225M

0.38%

2,610 $428M

0.63%

2,665 $420M

0.61%

FY 2013 FY 2014 FY 2015 FY 2016

Hospitals Receiving Penalty

Total Readmissions Penalties

Average Penaltyper Hospital8

Increase in maximum penalty and expansion to new conditions in FY 2015 both contributed to rise

Hospital Penalty Performance Over Time

October 2016

HRRP expands to CABG7


Moving forward, readmission reduction efforts are not going to get easier. In fact, CMS is adding CABG as the first CV procedure to be part of the HRRP beginning FY 2017.

The introduction of the CABG metric presents new challenges for CV programs, many of which are outlined here. Hospitals that report poor CABG performance will be penalized even if they perform well on other conditions already included in the program.

While penalties go into effect in October 2016, institutional performance today counts toward future penalties. 2017 penalties will be based on performance from July 2012 through June 2015, meaning there is no time to lose in putting a strategy in place to prevent future penalties.

Ready or Not…CABG Added to the HRRP for FY 2017

Source: Suter SG, et al., “Hospital-Level 30-Day All-Cause Unplanned Readmission Following CABG: Updated Measure Methodology Report,” http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html; Cardiovascular Roundtable research and analysis.

1) Will not be finalized until FY2017 IPPS ruling, yet this timeframe is consistent with past years.

Breaking Down the New 30-Day CABG Readmissions Metric

CABG Added to Current HRRP Conditions

• Claims-based, risk-adjusted metric

• All-cause, unplanned readmissions

• Hospital penalized for excess CABG readmissions even if it performs well for other conditions

Targeting the Admitting Hospital

• Penalizes index admitting hospital versus discharging hospital

• This is different from the other HRRP measures (e.g., HF, AMI), which target discharging hospital

Hospitals Are Already Under the Microscope

• Penalties start with FY 2017 payment (October 2016)

• Will likely be based on performance from July 1, 2012 to June 30, 20151

Possibly Excluding the Most Vulnerable

• Procedure Criteria: Isolated CABG only; does not include CABG plus valve or valve surgeries

• Hospital Criteria: Programs with more than 25 CABGs over three-year measurement period (excluding Medicare Advantage)


Source: Suter SG, et al., “Hospital-Level 30-Day All-Cause Unplanned Readmission Following CABG: Updated Measure Methodology Report,” http://www.cms.gov/Medicare/ Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html; MedPAC, “Report to the Congress,” June 2007; Cardiovascular Roundtable research and analysis.

1) From 2001 report (1998-1999 data) to most recent 2013 report (2011-2012 data).

2) Society of Thoracic Surgeons.3) Peripheral vascular disease.4) Implantable cardioverter defibrillator.5) Carotid artery stenting.6) Carotid endarterectomy.

It came as no surprise that CMS targeted CABG in the HRRP. Due to its high cost, volume, and readmission rate, CABG was one of seven conditions MedPAC—the Medicare Payment Advisory Committee—called out in a 2007 report to Congress that inspired the readmission penalty program, four of which have already been added to the HRRP.

Nor is CMS the first to target CABG. In fact, Pennsylvania has publicly reported rates since 2001, even by physician. California and New York have also joined the mix, and the Society of Thoracic Surgeons reports for all participating hospitals.

However, CABG is not the only procedure that should be on a CV program’s radar. Readmissions following other CV procedures also have significant impact nationally, foreshadowing increased scrutiny going forward. Included in the accompanying table is the Cardiovascular Roundtable’s assessment of the greatest immediate opportunities for CV programs based on impact and likelihood to inflect.

No Surprise That CABG Is in the Crosshairs

But CABG Is Not the Only Procedure to Consider

CABG Readmissions Already Facing Scrutiny

STS2 National DatabaseReadmissions is a metric in the Adult Cardiac Surgery Database

New YorkBegan publicly reporting CABG readmissions in 2014

CaliforniaAdded 30-day readmissions to annual CABG report in 2012

Hospital Risk-Standardized30-Day CABG Readmission Rate

Medicare, January 2009–September 2011, by Percentile

15.6%

16.8%

17.9%

25thPercentile

50thPercentile

75thPercentile

n=150,900 Admissions from 1,195 Hospitals

PennsylvaniaBegan publicly reporting 30-day CABG readmission rates in 2001; have since seen a state-wide decline from 15.3% to 11.8%1

National Impact of 30-Day Readmissions from Key CV Procedures

HCUP 2012 All-Payer, All-Cause

ProcedureReadmissionRate

Mean Cost per Readmission

Roundtable Assessment of theLevel of Priority for CV Programs

CABG 12.7% $12,730 High: Already counting toward penalties in the HRRP

Valve 17.0% $15,106High: Requires similar strategies as CABG readmission reduction; TAVR programs are already facing scrutiny

PCI 11.3% $12,371Medium: Recent studies question if hospitals are able to greatly inflect PCI readmissions due to wide variability in causes that may not be in hospital’s control

PVD3 17.5% $15,163Medium: Identified in 2007 MedPAC Report to Congress as an area of focus, although not currently in the HRRP

PermanentPacemaker

12.1% $11,498Medium: Not currently on CMS’ radar for the HRRP, but have high volume, readmissions

ICD4

Implant13.5% $13,125

Medium: Not currently on CMS’ radar for the HRRP, but have high volume, readmissions

CAS5 8.7% $12,838Low: Relatively low volume and rate of readmissions; not always directly within cardiology program purview

CEA6 9.5% $12,503Low: Typically not directly within cardiology program purview as largely performed by vascular or general surgery


Source: MedPAC, “Report to the Congress,” June 2007; FY 2014 IPPS Final Rule, CMS; Horwitz LI, et al., “Hospital-Wide All-Cause Unplanned Readmissions Technical Report,” July 2014; Cardiovascular Roundtable research and analysis.

1) Only includes isolated CABG, excluding CABG + valve.2) MS-DRGs 252-254.3) Hospital-wide readmissions.4) Inpatient Quality Reporting.5) Accountable care organizations.

Despite the impact of other CV procedures, CABG remains the only one in the penalty program so far, leaving two of the seven proposed conditions still unaccounted for: PCI and “other vascular.”

The current rationale for excluding these two is that volumes are decreasing and shifting toward the outpatient setting. There is also debate over whether or not causes of PCI readmissions are too variable to hold programs accountable. However, MedPAC continues to lobby for inclusion of PCI in the program, and CMS has indicated they are looking into an appropriate readmissions measure for PCI.

Whether or not PCI, vascular, or other procedures are included in the readmissions program, they may indirectly become a focus in the future, given increasing support for a hospital-wide—or all-condition—readmissions metric. Many organizations are already tracking and publicly reporting this metric: it is in the inpatient quality reporting program, public on Hospital Compare, and tracked for Medicare Shared Savings Program participants. MedPAC is also encouraging CMS to add the metric to the readmission reduction program, although CMS has declined thus far. As hospital-wide readmissions receive more focus, CV services will likely be a first target.

Other CV Procedures Left Out of the HRRP…for Now

All-Condition Readmission Tracking Already Here

Conditions MedPACIdentified for HRRP

1 Heart failure

3 Pneumonia

4 AMI

5 CABG1

6 PCI

7 Other vascular2

2 COPD

Rationale for Not IncludingPCI and Vascular for Now

Decreasing volumes

Procedures largelyshifting outpatient

Cur

rent

ly I

nclu

ded

Studies suggest causes of PCI readmission are too variable

Never Say Never“We are working towards finding a suitable PCI measure for the HRRPand may introduce such a measurein future rulemaking.”

CMS, FY 2014 IPPS Final Rule

Hospital IQR4 Program

Included HWR measure for FY 2014 reporting

National QualityForum (NQF)

Officially endorsed HWR measure in 2012

Hospital Compare

HWR rates publiclyreleased as of 2013

MedPAC

2013 and 2014 Reports to Congress recommended CMS add HWR to HRRP

Medicare SharedSavings Program (MSSP)

Participant ACOs5 must submit HWR as one of the MSSP quality metrics

HWR Metric in Brief

• CMS hospital-wideall-cause unplanned readmissions measure

• Developed in 2012

• Measures 30-dayrisk-standardized readmission rate for all discharged patients

• Also referred to as“all-condition” readmissions

National Programs Increasing Scrutiny Over HWR3


While avoiding penalties is clearly a driver of readmissions reduction for CV programs, it is just one of many important reasons for preventing unnecessary readmissions.

First, strategies used to reduce readmissions will also improve care coordination and quality across the continuum, and these impacts can extend beyond thirty days. Second, as no patient wants to return to the hospital if it can be avoided, readmission avoidance improves patient experience.

Third, eliminating costly readmissions is pivotal to success under any risk-based contract model (e.g., ACOs, bundled payments) as each readmission can significantly impact margins. Fourth, readmissions rate transparency will only continue to increase and will likely factor in to physician referral decisions.

Finally, preparing for future total utilization scrutiny: 30-day readmissions is likely just the tip of the iceberg. We are already seeing more comprehensive utilization metrics introduced, such as IQR’s AMI and HF “excess days” metrics that capture all active utilization.

Together, these drivers substantiate the importance of focusing on readmission reduction efforts. The HRRP presents an opportunity to justify the time and investment to build a platform for cross-continuum care now and to prepare for what’s to come.

Losing Sight of the Forest for the Trees?

Source: Cardiovascular Roundtable research and analysis.

Penalty Avoidance Just One Reason to Reduce Readmissions

Cross-Continuum Quality and Coordination

Readmission strategies buildan infrastructure for longitudinal care coordination that can extend beyond 30 days and improve long-term outcomes

AMI and HF “excess days” metrics added to IQR in FY 2016, capturing all acute utilization for 30 days post-discharge

Re-hospitalization after a procedure seen as a clear care breakdown—more so than for medial care (e.g., HF)—leading to patient anxiety, dissatisfaction

Total Utilization Scrutiny

Patient Experience

Additional Drivers to Reduce Readmissions

Success inRisk-Based Payment Models

Programs bundling for a CV procedure or in an ACO must avoid readmissions to manage total costs

30-day PCI readmissions public on Hospital Compare, tracked in CathPCI registry; SurgeonRatings.org site allows patients to compare surgeons on 90-day readmission rates, other outcomes

Readmissions Transparency


While these efforts may seem daunting, CV programs are not starting from scratch. In fact, many strategies programs are already using to avoid heart failure readmissions address the key causes of procedural readmissions as well. It is now time to expand these efforts beyond heart failure.

For example, psycho-social factors drive many readmissions across conditions. A recent study found CABG patients are three times more likely to be readmitted if they live alone without social support.

Patient activation is also critical for both medical and procedural patients. However, following an invasive procedure, patients are even more likely to return unnecessarily due to anxiety over their recovery. Additionally, while care transitions are a priority with heart failure, effective transitions are just as critical for procedures. As many as 60% of 30-day CABG readmissions occur during the first week post-discharge.

Finally, supporting post-acute providers remains a necessity given the complexity of procedural follow-up care.

It is encouraging to know there is a foundation to build from, but supporting transitions and post-discharge care only tackles a portion of procedural readmissions. This is largely due to a challenge with procedural patients not present with medical patients: complications from the procedure itself.

CV Programs Not Starting from Scratch

Source: Murphy BM, et al., “Living Alone Predicts 30-Day Hospital Readmission After CABG,” European Journal of CV Preventative Rehabilitation, 2008, 15:210-215; Price JD, et al., “Risk Analysis for Readmission After CABG,” Journal of the American College of Surgeons, 2013, 216:412-419; Cardiovascular Roundtable interviews and analysis.1) Home health, SNF, rehab, other PAC.

Critical to Expand the HF Cross-Continuum Mind-set to Procedures

Key Strategies forReducing HF Readmissions…

Targeting sociodemographic and psychosocial risk factors

Activating patientsto self-manage

Ensuring effectivecare transitions

Partnering with post-acute providers to manage chronic CV disease

Percentage of 30-day CABG readmissions that occur 1 to 7 days post-discharge

…Address Similar Challengesfor Procedural Patients

60%

Many of our CABG readmissions are due to patient anxiety—they don’t know what to expect, and come back with symptoms that are just normal healing.”

VP of CV Services in the South

Increased risk of readmission after CABG for patients who live alone3x

Percentage of readmitted CABG patients that had been discharged to post-acute care1 following index admission

71%


In fact, the medical community largely agrees that the primary root causes of post-procedure readmissions are infections and comorbidities. Results from two representative clinical studies for CABG and PCI illustrate these root causes, which are consistent across the literature.

For CABG, the top drivers are heart failure, post-op infections and complications, AFib, and chest pain. As for PCI, factors causing readmission are largely chest pain, followed by repeat PCI and heart failure. The trend remains consistent for other CV procedures as well (e.g., valve surgery, vascular).

As a result, to reduce procedural readmissions it is not only necessary to enhance care transitions, but also address the infections and comorbidities that cause patients to return to the hospital.

But New Challenges Emerge

Source: Li Z, et al., “Hospital Variation in Readmission After CABG in California,” Circulation CV Quality and Outcomes, 2012, 5:729-737; Wasfy JF, et al., “Clinical Preventability of 30-Day Readmission After Percutaneous Coronary Intervention,” Journal of the AHA, September 26, 2014; Cardiovascular Roundtable research and analysis.

1) Exact order varies by study; however, infections and comorbiditiesare consistently the primary root causes for procedural readmissions.

2) ICD-9-CM code referring to complications of nervous, circulatory, respiratory, digestive, and/or urinary systems.

Infections, Comorbidities Are Primary Drivers of Procedural Readmissions

CABG PCI

Post-operative infections13%

Representative Studies Illustrate Root Causes of 30-Day Readmissions1

Percentage of Readmitted Patients in Select Study

Heart failure15%

Other complications ofsurgical and medical care210%

Cardiac dysrhythmias7%

Angina/chest pain5%

Staged PCI withoutnew symptoms7%

Angina/chest pain38%

Heart failure6%

Vascular bleeding/ complication of PCI4%

Gastrointestinal hemorrhage3%

Study in Brief: 30-Day Readmissions After CABG in California

• 2012 study published in Circulation: Cardiovascular Quality and Outcomes

• Retrospectively analyzed 11,823 California patients who underwent isolated CABG in 2009 to identify reasons for and predictors of 30-day readmissions

• Most common reasons for readmission (primary diagnoses) were comorbidities and complications or infections related to procedure and recovery

Study in Brief: Clinical Preventability of 30-Day Readmission After PCI

• 2014 study published in the Journal of the American Heart Association

• Retrospectively analyzed 9,288 PCIs performed at Massachusetts General Hospital and Brigham and Women’s Hospital from 2007 to 2011 to evaluate reasons for 30-day readmissions

• Most common causes identified were staged PCI without new symptoms, vascular bleeding/complications of PCI, and congestive heart failure

• 43% of readmissions were deemed preventable


There are many key opportunities across the continuum for overcoming the aforementioned drivers of procedural readmissions.

The first three strategies target infections: minimizing procedural complications, optimizing recovery, and proactively identifying infection post-discharge. The latter three focus on enhancing cross-continuum care: enabling patients to self-manage, streamlining transitions, and ensuring high-quality longitudinal care.

These strategies require time and investment, but there are concrete benefits even beyondreadmissions reduction. For example, these strategies can also improve patient experience, increase capacity, and reduce costly excess days due to infection, emphasizing the value of a comprehensive procedural readmission reduction strategy to the entire hospital.

Identifying Strategies to Target Root Cause Issues


Tactics Relevant Across CV Procedures

Enhance post-discharge care delivery

Minimize risk of procedural complications

Optimize recoveryto reduce infections

Coordinate effective care transitions

Ensure complications are identified promptly

Engage patientsand family

Greatest Opportunities for Reducing Procedural Readmissions

Strategies Also Support Broader Service Line Goals

Cost Reduction

• Reduce costly complications

• Limit time spent in high-cost ICU

Quality

• Increase cross-continuum coordination

• Enhance patient experience

Efficiency

• Reduce length of stay, freeing capacity

• Avoid unneededED visits


This publication provides eight lessons for developing a comprehensive strategy for reducing CV procedural readmissions, complete with best practice solutions alongside implementation tools.

First, before diving into readmissions tactics it is essential to start with high-quality procedures. As such, the first chapter focuses on building the foundation for procedural excellence. The following chapters provide guidance on perfecting inpatient care, successfully transitioning out of the acute setting, and partnering with post-acute care providers managing CV patients in the long term.

While many of the cases in this publication specifically target CABG—as that has been the primary focus for most procedural readmission reduction efforts to-date—these lessons are relevant beyond CABG, addressing the key readmissions causes of other CV procedures (e.g., PCI, vascular interventions). In fact, many will help bolster heart failure and AMI readmissions efforts as well. As such, these lessons will support all CV programs in developing or enhancing their readmission reduction strategy.

Reducing CV Procedural Readmissions


Lessons for Developing a Cross-Continuum Procedural Care Strategy

• Data-Driven Performance Improvement

• High-Caliber Procedural Team

• Appropriate Patient Selection

Special Report:Build a Foundation for CV Procedural Excellence

1. Reduce Risk of Post-Procedure Complications

2. Coordinate Care Across Patient Recovery

2Perfect Inpatient Care to ImproveLong-Term Outcomes

3. Enable Patients to Self-Manage

4. Optimize the TransitionalCare Team

5. Maximize High-Risk Transition Clinics for Procedural Patients

3Ensure Effective Post-Discharge Transitions

6. Ensure Appropriate Cardiac Rehab Utilization

7. Coordinate with Providers Delivering Ongoing Care

8. Prevent Unnecessary Admission from the ED

4Optimize LongitudinalCare Management

1


• Data-Driven Performance Improvement

• High-Caliber Procedural Team

• Appropriate Patient Selection

Special Report: Build a Foundation for CV Procedural Excellence

Chapter 1


When developing a comprehensive readmission reduction strategy, it is tempting to immediately focus efforts on known readmission reduction tactics, like discharge planning or follow-up phone calls. However, in order to have successful post-procedure transitions, you must begin further upstream with a high-quality procedure. It is therefore critical to first build a quality infrastructure that enables successful procedures.

While “quality” encompasses more than can be addressed in this chapter, there are three foundational elements that must be in place for exceptional procedural outcomes: data-driven performance improvement, a high-caliber procedural team, and appropriate patient selection. With this quality infrastructure in place, CV programs will be able to better execute the remaining imperatives discussed in this publication.

Don’t Put the Cart Before the Horse


Readmission Reduction Requires a Strong Quality Infrastructure

1. Experienced operators

2. Cohesive team

3. Embedded accountability

1. Optimal treatment choice

2. Risk-tailoredcare pathways

Data-DrivenPerformance Improvement

High-Caliber Procedural Team

Appropriate Patient Selection

Perfect Inpatient Care Delivery

Ensure Effective Transitions

Optimize Post-Discharge Care

Foundational Elements of a High-Quality CV Procedural Program

Procedural Readmissions Reduction Strategies

Build a Quality Foundation

1. External benchmarking

2. Internal rootcause analysis

3. Ongoing performance monitoring


Data-Driven Performance Improvement

A structured, data-driven performance improvement process is fundamental to any high-quality CV program, both in that it enables early identification of causes of suboptimal outcomes, but also allows programs to target their limited time and resources toward opportunities that will yield the greatest impact.

In the context of a readmissions reduction program, the first step is understanding current readmission performance. The Cardiovascular Roundtable’s Hospital Benchmark Generator tool enables programs to compare DRG-level readmission rates to a cohort of their peers to determine targeted opportunities for improvement.

Element 1: External Benchmarking


Hospital Benchmark Generator

• Provides financial, operational, and quality benchmarks (including readmissions) at the service line, sub-service line, and DRG level

• Benchmarks institution performance against a user-defined peer cohort

• Helps CV programs identify internal opportunities for improvement to target readmission reduction efforts

• Access the tool at: advisory.com/cr/tools

Roundtable Tool Benchmarks Hospital Readmission Performance

Readmission Benchmarks in Tool

Risk-adjusted 30-day readmission rates for CABG, HF, AMI, COPD, stroke, pneumonia, THA/TKA

3-day raw readmission rate

30-day raw readmission rate

Same-site versus other site

30-day raw readmission ratesfrom post-acute care providers


External benchmarks will provide program leaders insight into procedures requiring more attention, but to move the dial in these areas it is crucial to understand why these patients are returning through an internal root cause analysis, our second element.

As an example, New Hanover Regional Medical Center in Wilmington, NC formed a hospital-wide readmission reduction committee in Spring 2014. In order to focus on strategies that yielded the greatest improvement, the committee analyzed all care coordination strategies used at their program and tied them to patient outcomes to determine which had outsized impact on readmissions across all HRRP conditions (i.e., HF, AMI, pneumonia, COPD, THA/TKA, and CABG). From the 23 frequently utilized strategies reviewed, New Hanover isolated six that were responsible for 80% of readmission reductions and made these the top focus of their readmissions strategy.

When CABG readmissions became a priority later that year, CV leaders then conducted a CABG-specific root cause analysis to augment the master list of tactics with procedure-specific strategies. They pulled one year of CABG records and identified the top three causes of unnecessary readmission: patient anxiety, AFib, and inappropriate admissions from the ED without a surgical consult.

Element 2: Internal Root Cause Analysis

Source: New Hanover Regional Medical Center, Wilmington, NC; Cardiovascular Roundtable interviews and analysis.

1) New Hanover Regional Medical Center.2) E.g., case managers, social workers, unit nurses, care coordinators.

NHRMC’s1 Data-Driven Audit Informs CABG Readmission Strategy

20% of Tactics Yielding80% of Impact

1. Readmission risk stratification

2. Patient-provider communication board

3. Teach-back for patient education

4. Inpatient pharmacist-led med-rec

5. Follow-up visit scheduled pre-discharge

6. RN transition call within 48 hours

• CV leaders pulled one year of CABG patient records

• Identified top causes of readmissions

• Convened team to develop and carry out a solution to address each

Top Modifiable Causes of CABG Readmissions

1. Patient anxiety

2. Atrial fibrillation

3. Inappropriate admissions from ED without surgical consult

Hospital-Wide Readmission Audit CABG Root Cause Analysis

• Interviewed care team2 to uncover all care coordination tactics used for HRRP conditions

• Identified 23 primary strategies

• Internal analysis determinedwhich tactics correlated withlower readmissions

Case in Brief: New Hanover Regional Medical Center

• 650-bed teaching hospital in Wilmington, North Carolina

• Cardiac surgeons are independent but affiliated through a PSA

• Hospital-wide readmission reduction committee completed a care coordination audit of all tactics used to reduce readmissions, linking them with patient outcomes

• Of 23 frequently utilized strategies, the analysis identified six with the greatest impact; committee is implementing these strategies hospital-wide and monitoring impact

• Began a dedicated CABG readmission reduction initiative in October 2014 in preparation for the addition of CABG to the HRRP; conducted a CABG-specific root cause analysis to identify additional opportunities

• Both hospital-wide and CABG-specific readmission committees meet monthly to review progress on implementing the top strategies and revise them as needed

• CV leaders added CABG readmissions to the monthly cardiac surgery dashboard, which they review monthly with surgeons to monitor improvement


With these targets in mind, New Hanover built workplans to address each cause.

New Hanover’s multidisciplinary cardiac surgery readmissions committee used LEAN methodology to break down the key root causes they identified and develop workplans to address each.

For example, to overcome patient anxiety, which often leads patients to the ED unnecessarily, they established cardiac surgery home health visits and enhanced patient education. They also devised tactics to address post-procedure AFib and inappropriate admission from the ED.

The workplans assign responsibility and a timeline for each initiative. The team reviews performance data monthly so they can revise their strategies as necessary.

Focusing on Strategies That WorkSystematically Targeting Root Causes of CABG Readmission

Primary Causes ofCABG Readmissionat NHRMC

1. Patient anxiety

2. AFib

3. Unnecessaryadmission from ED

Apply strategies used in NHRMC Readmission Reduction Project to CABG patient population

Enhance CABG education delivery

Implement CV surgery one-week follow-up appointment

Utilize community pharmacy, paramedics, and home healthfor CABG patients

Expand chest pain observation unit

Roll out AFib short stay protocol

Countermeasures

Implementation Plan

Task Who WhenExpected Outcome

Revise home care protocol

Confirm implementation with all home health agencies

Plan outlines owner, goal, and deadline for each

22 tasks support the countermeasures

• VP of cardiac services

• CV network director

• Cardiac surgeons

• Cardiologists

• Home health

• Pharmacy

• Community paramedics

• ICU nurses

• CV surgery educators

• Case managers

• CV floor nurses

• Finances

Cardiac Surgery Readmissions Committee Meets Monthly to Review Progress

Workplan Tracks Progress in CABG Readmission Initiatives



New Hanover has also updated their cardiac surgery quality dashboard to monitor ongoing performance of their new readmissions reduction initiative, the third element within data-driven performance improvement. The dashboard has approximately 50 indicators, including hospital- and physician-level readmission rates. New Hanover reviews these indicators during monthly quality meetings with the cardiac surgeons so they can identify solutions in real time. The complete dashboard is available in the online Appendix.

CV leaders at New Hanover find this data-driven approach has helped them develop a resource-efficient and effective CABG readmissions reduction strategy.

Element 3: Ongoing Performance MonitoringCABG Readmissions Added to Monthly Cardiac Surgery Dashboard

Cardiac Surgery Quality Dashboard

Building a Useable Tool

• Separate dashboards for isolated CABG, isolated AVR, CABG + AVR

• 50 indicators including all STS metrics plus other program priorities

• Hospital- and physician-level performance

• Benchmark performance against STS

Immediate Impacts of Approach

• CV administrators review with CV surgeons monthly

• Clinicians have become aware of true performance and patient readmissions

• Encourages collaboration to devise solutions (e.g., evidence-based protocols, risk stratification tools)

Access the dashboard templateon the online Appendix

Added CABG readmissions in October 2014

Use STS as benchmark when available



High-Caliber Procedural Team

The first pillar “data-driven performance improvement” helps programs identify top opportunities for advancement. However, it is difficult to improve performance without the support and experience of those providing care. Therefore, assembling a high-caliber team is the second component for building a strong foundation for procedural excellence.

At baseline, an exemplary team requires clinicians having sufficient experience. For years there’s been debate over the relationship between program volumes and outcomes. This is particularly relevant for CV, because for several years while volumes have decreased or stagnated the number of open heart and PCI programs increased, limiting volumes available to individual programs.

This issue has now been brought to a national stage, as in early 2015 US News released an analysis of four procedures—including congestive heart failure and bypass—concluding higher-volume programs had lower mortality, and vice versa.

Element 1: Experienced Operators

1) Conditions analyzed: bypass surgery without valve, CHF, elective hip and knee replacement, COPD.

2) Dartmouth-Hitchcock Medical Center, Johns Hopkins Medicine, and the University of Michigan.

Volumes-Outcomes Link Still a Relevant—and Debated—Issue Today

Issue Brought to a National Stage

“Patients at thousands of hospitals face greater risks from common operations, simply because the surgical teams don’tget enough practice.1”

May 18, 2015

Risks Are High atLow-Volume Hospitals

2011 AHA/ACC Guidelines for CABG

“In general, the best results are achieved most consistently by high-volume surgeons in high-volume hospitals…

However, many low-volume programs achieve excellent results, perhaps related to:

• Appropriate case selection

• Effective teamwork among surgeons, nurses, anesthesiologists, perfusionists, and PAs

• Adoption of best practices derived from larger programs.”

Guidelines Advise Not toView Volumes in Isolation

“[Three health systems2] are planning to impose minimum-volume standards that will bar hospitals in their systems from performing certain procedures unless both the hospitals and their surgeons do them often enough to keep their skill level up.”

May 19, 2015

Hospitals Move to Limit Low-Volume Surgeries

Source: Sterberg S, Dougherty G, “Risks Are High at Low-Volume Hospitals,” US News, May 18, 2015; Cardiovascular Roundtable research and analysis.


As a result, some health systems are stepping forward with strict volume thresholds for their hospitals and physicians, and several organizations have suggested standards, outlined here. Whether such strict volume requirements are necessary is still up for debate. In fact, society guidelines for CABG and PCI are hesitant to provide volume thresholds, indicating that low-volume programs can achieve excellent results if there are safeguards in place (e.g., appropriate case selection, teamwork, peer review, training).

However, while volumes alone may not be the only predictor of operator quality, in most circumstances higher operator volumes is optimal. It therefore rests on CV leaders to ensure their clinicians have the volumes to maintain experience and support outcomes, as explored on the following page.

Societies and Organizations Offer Some Guidance

Source: Hills, LD, et al., “2011 ACCF/AHA Guideline for CABG,” Circulation, 2011; Harold JG, et al., “ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures,” JACC, 2013; The Leapfrog Group, “Fact Sheet: Evidence-Based Hospital Referral,” April 1, 2015; Clark C, “Limits Urged on Surgeries by Low-Volume Providers,” HealthLeaders Media, May 20, 2015; Cardiovascular Roundtable research and analysis.

Procedure Hospital Volume Physician Volume Statement or Group

CABG

Programs performing<125 CABG/year might consider affiliating with a high-volume tertiarycenter

N/A2011 ACCF/AHA Guideline for CABG

PCI ≥200/year≥50/year, averaged over two years

2013 Clinical Competence Statement on Coronary Artery Interventional Procedures

Primary PCI for STEMI

• ≥200 elective PCI/year

• ≥36 PCI for STEMI/year

• ≥50 elective PCI/year

• ≥11 PCI for STEMI/year

2013 Clinical Competence Statement on Coronary Artery Interventional Procedures

Mitral Valve Repair

≥20/year ≥10/year“Take the VolumePledge” Campaign

ComplexAortic Surgery

≥20/year ≥8/year“Take the VolumePledge” Campaign

Carotid ArteryStenting

≥10 procedures/year ≥5/year“Take the VolumePledge” Campaign

AVR ≥120/year ≥22/year The Leapfrog Group

TranscatheterMitral Valve Repair

• ≥25 mitral valve surgeries for severe MR/year, including ≥10 mitral valve repairs

• ≥1,000 cath/year including ≥400 PCIs

Interventional cardiologist with >50 structural procedures per year including ASD, PFO and trans-septal punctures

CMS National CoverageDetermination for TMVR

TAVR

Existing TAVR programs:• ≥20 AVRs/year or ≥40

AVRs over 2 years• ≥1,000 cath/year

including ≥400 PCIs

Existing TAVR programs: CV surgeon and interventionalist combined experience of ≥20 TAVR in prior year or ≥40 TAVR in prior 2 years

CMS National CoverageDetermination for TAVR

Available Volume Threshold Recommendations for CV Procedures


There are many strategies to help CV proceduralists and surgeons meet suggested volume thresholds, for example, identifying opportunities to increase volumes by increasing patient access and capturing latent demand. Alternatively, they can consider opportunities to consolidate procedural programs among sites within a given market, or partnering with other local hospitals.

The Cardiovascular Roundtable has covered many of these strategies in depth in recent work to provide guidance on identifying strategies suitable for a range of programs, outlined here.

The following case illustrates one unique strategy for ensuring adequate volumes for CV physicians.

Strategies to Build and Sustain Needed VolumesHospitals Must Support Clinicians in Maintaining Procedural Competency

Evaluate ability to capture needed volumes before expanding service offerings at a site

Guide for Assembling theAccessible CV Network

• Realigning CV service distribution

• Evaluating CV partnerships

• Elevating access to improve market capture

Partner with other hospitals to allow physicians to perform procedures there to increase volumes and experience

Consolidate procedural programs across sites in the same geographic market

Cardiovascular Roundtable Resources to Support These Efforts

Select Opportunities to Ensure CV Programs Have Necessary Volumes

CV Blueprint for Growth

• Evaluating new market opportunities

• Capturing latent demand

• Expanding reach through partnerships

Increase volumes by capturing latent demand, expanding market footprint, and increasing access

CV Regionalization and Network Strategy

• Assessing distribution of services

• Reallocating services to meet demand

• Mitigating pushback to reallocation


Similar to many institutions across the country, Tucker Health1 was facing declining interventional volumes. CV service line leaders recognized they needed to increase presence in secondary markets to ensure their employed interventionalists had enough procedural volume to work to top of license and maintain specialized experience.

At the same time, an independent physician practice in the region that did not offer interventional services realized they were losing patients they had to refer off to another system for those procedures. However, they did not have sufficient volume to hire a full-time interventionalist themselves.

Recognizing the potential for collaboration, Tucker leaders met with the practice and developed a leasing arrangement in which Tucker specialists would perform all the practice’s interventions.

Partnership Helps Secure Proceduralist Volumes

Source: Cardiovascular Roundtable interviews and analysis. 1) Pseudonym.

Tucker Health1 Leasing CV Specialists to Independent Physician Group

Independent Multispecialty Physician Practice

Challenged to meet demand with existing physician resources

• Increasing demand for interventional CV services in patient panel

• Insufficient volume to fill a full-time interventionalist’s schedule

Tucker Health

Needed to expand market capture to meet interventionalist capacity

• Employed interventionalists had ability to take on a higher case load

• Required additional procedural volumes to ensure specialists were working to top of license

Programs Challenged to Match Specialist Capacity with Demand

Case in Brief: Tucker Health

• Integrated health system in the Northeast

• CV leaders recognized they needed to significantly expand their market capture to ensure their interventionalists were able to maintain competency and productivity.

• CV administrator identified an independent multispecialty physician group that commonly referred to Tucker for CV services; discussions revealed the group had latent demand for interventional CV services, but insufficient volume to justify recruiting a full-time interventionalist into the practice

• Established a lease arrangement to lend Tucker interventionalists to the physician group, allowing the practice to have their procedural cases performed within the group without having to invest in a full-time interventionalist’s salary or costs

• Arrangement successfully allows Tucker to maximize their interventionalist’s time on procedural cases, strengthen referral streams, and extend their presence into new markets

• Cost-effective strategy primed for replication with physician-led ACOs in market


In this arrangement, Tucker leases 20% of their employed interventionalists’ time to the physician practice and bills at fair market value. While leased, the interventionalists travel to local cath labs to perform all of the practice’s cases. The financial reimbursement is split, with the professional fee going to the physician practice and the technical fee paid to the hospital where the procedure is performed—ideally, one of Tucker’s, but not required. Following the procedure, patients are returned back to the physician practice.

This arrangement has proven beneficial for all parties involved. Tucker has gained many strategic advantages from increased downstream referrals to enhanced market presence in the communities served by their interventionalists. The interventionalists’ increased workload enables them to maintain experience and work to top of license. Meanwhile, the physician group is able to reallocate its financial resources toward hiring a medical cardiologist rather than an interventionalist, which better suits their needs.

Tucker’s creative solution has enabled its hospital to sustain the interventional program, while still ensuring the quality and experience of their physicians.

Lease Agreement Sets Clear Parameters for Specialist Time, Coverage

Forming a Mutually Beneficial Partnership

Partnership Achieving Higher Value Care

Source: Cardiovascular Roundtable interviews and analysis.

Tucker Leases Specialist to Independent Practice

• 20% of interventionalist’stime leased to independent physician practice

• Remain full time employees of Tucker Health

• Physician group billed at fair market value

Specialist Performs Practice’s CV Procedures

• Physician practice fills interventionalist’s schedule with procedural cases on designated days

• Performed in nearest equipped facility

Split the Procedure Reimbursement

• Multispecialty groupreceives professional fee

• Hospital where procedureis performed (Tucker or elsewhere) receives technical fee

Patients Returned to Physician Practice

• Practice maintains control over their patient’s care post-procedure

• Interventionalist reassumes Tucker workload

Arrangement Proving Beneficial to All Stakeholders

• Maximizes interventionalistcase load with high-end procedures, enabling them to work at top of license

• Ensures sufficient volumes to maintain specialized experience and thresholds for competence

• Eliminates need to hire an interventionalist to keep patients within group

• Able to allocate investments toward hiring general cardiologists

• Ensures employed physicians maintain specialized experience

• Strengthens referral streams, increasing downstream volumes from interventional procedures

• Enhances market presence in new regions

Tucker Health Tucker Interventionalists

IndependentPhysician Practice


Enabling physicians to maintain experience is critical, but a high-caliber team must be just that:a cohesive team of multidisciplinary physicians, nurses, and staff. This is our second element.

Prism Hospital, a pseudonym for a hospital in the South, has hardwired multidisciplinary team-based care through their CV surgical home model.

In Fall 2013, CV leaders at Prism implemented a performance improvement initiative to improve performance against STS quality metrics for their CV surgery program. As part of this initiative, Prism recognized they were not attaining multidisciplinary input for their CV surgery patients, which was leading to suboptimal outcomes. Traditionally, patients were referred directly to an independent surgeon, which resulted in care variation and lack of multidisciplinary involvement. In response, Prism launched a multidisciplinary “CV surgical home” model that consists of standardized intake, care pathways, and protocols.

In this new model, there is a centralized intake process for all referrals, which initiates a standard care protocol that ensures multidisciplinary, coordinated, evidence-based care delivery from surgical intake through post-discharge transition.

Element 2: Cohesive Team

1) Pseudonym.

Case 1: Prism1 CV Surgical Home Ensures Multispecialty Participation

• Centralized intake for all CV surgery patients

• Hardwires multidisciplinary evaluation

• Ensures patient appropriatelyprepped for surgery

• Streamlines consults with specialists for high-risk, comorbid patients

• Consistent point of contact from intake to recovery and discharge

Traditional CVSurgery Patient Intake

Patient referred directly to cardiac surgeon

Inconsistent patient experience across sites and surgeons

Lacks multidisciplinary input in assessment and decision making

Patient not prepped for likely complications (e.g., pulmonary issues)

Limited coordination between physician and inpatient team

Team-Based Patient Intakein CV Surgical Home

Patient referred to surgical home, initiating standard protocol

Results in a Siloed Approach Enables Consistent Team-Based Care

Case in Brief: Prism Hospital

• 250-bed hospital located in the South

• Open heart program works with two independent CV surgery practices with four surgeons each, and performs about 20 open heart surgeries a month

• As part of a cardiac surgery quality initiative in 2013, launched a “CV surgical home” to hardwire multidisciplinary and evidence-based intake, assessment, and care pathways.

• Piloted the model with one surgery group, educating physicians, the OR team, and ICU nurses on how to use the order sets

• Given successful implementation, they rolled out the surgical home model tothe second surgery group

• The model has successfully improved their STS rating, adherence to evidence-based guidelines, and quality outcomes



The CV surgical home care pathway is outlined at right.

When a patient is referred, the administrator calculates the patient’s risk score. If elective, the cardiac surgeon will also visit the patient in the clinic to evaluate in person. This assessment informs patient preparation to minimize the risk of complications. For example, all patients see a pulmonologist for a pre-op “tune-up” and additional specialties as needed to address any comorbidities. The team then follows a standardized surgical home care plan throughout the procedure and recovery.

Critical to this model is that the surgical home is not limited to just CV surgery, but other relevant subspecialties like pulmonology, critical care, anesthesiology, and an administrator who will bring in other specialists as needed. This ensures a cohesive team and strategy for each surgical candidate.

Surgical Home Care Pathway Minimizes VariationEnsuring Multidisciplinary Assessment and Prep to Optimize Outcomes

• Calculate CV Surgical Risk Score for all scheduled patients

• Surgeon assesseselective cases in clinic

• Surgical home team discusses complicationrisk and mitigation strategies

• Communicate risk throughout stay

• All patients see pulmonologist for pre-op tune-up

• Team requests specialist consults (e.g., nephrology)to address comorbidities

• Contact critical care to prepare for high-risk patients

• Begin transition planning and coordinate with post-acute care

• OR team completes standardized hand-off

• ICU team uses evidence-based recovery order sets (e.g., patient education, blood management,early extubation)

• Surgical home team follows patient throughout recovery

Pre-OpAssessment

PatientPreparation

Procedureand Recovery

The CV Surgical Home

• ICU medical director

• Chief of anesthesiology

• CV physician assistant

• CV director

• CMO

• Cardiologist

• Chief of CV surgery

• Head of pulmonary critical care



Since implementing the model, Prism increased its STS rating, lowered intubation times and ICU length of stay, and reduced their readmission rates. In fact, this approach has proven so successful that after a year-long pilot with one surgery group, Prism rolled the surgical home model out to the other independent surgical group. It is now mandatory that all CV surgery patients are referred through the surgical home.

Prism’s case is just one example of the positive quality impacts of ensuring multidisciplinary care for CV patients.

Reaping the Benefits of a Coordinated ApproachImproving Performance on STS Metrics, Surgical Outcomes


New Model Quickly Yielding Results

STS rating increased from 1 to 2 stars

Reduced intubation times

Reduced ICU LOS

Reduced readmission rate

Successful Pilot Leads to Expansion

• Piloted surgical home model with one independent CV surgery group

• Monitored impact on STS quality metrics for one year

• Rolled out to the second surgery group

• Surgical home pathway now standard of care for all CV surgery patients


The next example takes the concept of building a cohesive care team one step beyond protocols to a dedicated CV surgery team that consistently works together.

Not long after Mount Carmel Health System expanded its open heart surgery program from one to two sites, CV surgeons began to notice that the OR team at the new site exhibited enhanced cohesion and teamwork, resulting in optimal procedural performance. Investigating further, they found the distinction was that the new program had one dedicated OR team just for CV surgery as opposed to generalist OR teams at the other site.

Therefore, upon the request of the surgeons, Mount Carmel merged the teams to create one dedicated CV surgery OR team for the system.

Elevating Performance of the Entire Operator Team

Source: Mount Carmel Health System, Columbus, OH; Cardiovascular Roundtable interviews and analysis.

1) CABG program expanded to a third site following dedicated team rollout.2) Cardiovascular intensive care unit.

Case 2: Mount Carmel’s Dedicated System CV Surgery Team

CV-specific surgery team

Shared surgery team Dedicated CV

surgery team

• CABG programs at two sites

• CV surgeons rotate, but OR teams (nurses, surgery techs) site-specific

• West campus OR team shared across service lines

• East campus had a dedicated CV OR team, which surgeons felt led to greater cohesion, skill set and outcomes

Original CV Surgery Staffing Model Disparate Across Sites

Floating Team ElevatesQuality System-Wide

Mount Carmel West

Mount Carmel East

Mount Carmel West

Mount Carmel East

St.Ann’s1

• Merged teams to create one dedicated CV surgery team

• Float to perform all open heart surgeries across the system

• Share scheduled proceduresand call coverage

• Model builds team experience, ensures consistency and quality

Case in Brief: Mount Carmel Health System

• Four-hospital system in central Ohio with two cardiac surgery programs about 15 miles apart at Mount Carmel East and West

• While Mount Carmel West shared their surgery team (nurses and techs) with other specialties, the newer CABG program at Mount Carmel East formed a dedicated team

• The employed cardiac surgeons who performed surgeries at both sites found that the dedicated CV surgery team exhibited greater team cohesion and skill level, as they could focus just on CV and consistently worked together

• In spring 2014, upon suggestion from the CV surgeons, CV leaders merged teams to create one dedicated CV surgery team to cover cardiac surgeries across all campuses including Mount Carmel St. Ann’s

• Surgical and perfusion teams now report to system managers while CVICUs2

report to site managers.

• Strategy has contributed to overall quality performance improvement against STS metrics, improved staff and physician satisfaction, enhanced call coverage efficiency, and reduced the number of staff required to cover three campuses

• Following expansion of cardiac surgery program, the collaborative team is now identifying metrics with associated goals for improvement


The system CV surgery team consists of a consistent, dedicated group of techs, nurses, and a nurse team lead, who work with the system’s four cardiac surgeons. When Mount Carmel first developed the team, OR staff performing CV surgeries were able to opt in, with the understanding that only those who joined the dedicated team would be able to cover cardiac surgeries going forward.

The team reports now to a system-level manager, and has standard assignments across the three sites based on volume. One of the primary benefits of this model is in call coverage, as all staff are cross-trained to cover any of the programs and surgeons. To support this, they’ve standardized equipment and training as well.

Skilled Team Available at All Times for All Sites

1) Perfusionists (eight across four hospitals) and anesthesiologists are currently separate.2) Meets state regulations for surgery on site for high-risk PCI and EP procedures.

Model Allows Flexibility for Shifting Census, Call Coverage

System CV Surgery Team1

Average Staffing Model

• Nurse team lead

• Eight nurses

• Five surgery techs

• Four surgeons

Team lead reviews system-wide scheduled surgeries each morning

Team Selection Process

• CV leaders explained to both OR teams the benefits of the model to patients and clinicians

• Must live within 45 minutes of each campus to take call2

• A few staff members elected to remain with general surgery and no longer take CV cases

• Training and equipment is standardized across sites

Team Lead Manages Daily Staffing Based on Demand

West

• 2 nurses

• 1 tech

East

• 4 nurses

• 3 techs

St. Ann’s

• 2 nurses

• 1 tech

Anticipates complex procedures that may require overtime call and reassigns team as needed

Each team member can now provide call coverage for any site



While restructuring the surgical team model required careful planning and widespread buy-in, Mount Carmel has already realized significant benefits in quality, staff satisfaction, and efficiency as a result of the dedicated CV surgery team.

For example, it guarantees an experienced team is performing all cardiac procedures and reduces care variation across sites. Additionally, the CV program saved six FTEs through this model, which they would have had to hire to support the third open heart site that opened.

While it is difficult to tie quality impact to this strategy alone, as part of their broader cardiac surgery initiative, Mount Carmel has seen a reduction in post-op AFib, length of stay, and readmissions.

Together, the past two examples demonstrate how programs can elevate the quality of their procedural care team through hardwiring multidisciplinary collaboration and teamwork.

Impact Extends Beyond Quality

1) Quality improvement.

Approach Standardizes Processes, Improves Team Cohesion, Efficiency

Surgeon satisfaction with increased experience and consistency in team

Staff satisfaction with ability to specialize and build comradery

Anticipates future changes in CV volumes and enables greater flexibility

Reduced surgery times as team consistently works together

Reduced surgical staff need by sixFTEs with expansionto third site

Served as a valuable recruitment tool when hiring new CV surgeons

Reduces care variation across hospitals

Quality Improvement Cost and EfficiencyProvider Satisfaction

Guarantees an experienced CV team performs each surgery

As part of broader CV surgery QI1

initiative, reduced AFib rate, LOS, and readmission



Building on a high-caliber care team, the third element is embedding accountability.

This is particularly important for readmissions, as a range of individuals can impact this metric. However, in a 2014 survey of Cardiovascular Roundtable members, only a minority reported tying incentives to readmissions for CV leaders or physicians. These low percentages indicate there is still room for improvement in increasing readmission accountability.

Element 3: Embedded Accountability

Source: 2014 Cardiovascular Roundtable CV Organizational and Leadership Structure Survey; 2014 Cardiovascular Roundtable CV Physician Alignment Strategy Survey; Cardiovascular Roundtable research and analysis.

Minority of Programs Tying Incentives to Readmissions Performance

CV Service Line Administrators

37%

CV DyadPhysician Leaders

Employed Cardiologists

48% 28%

Percentage of CV Stakeholders with Performance Incentives Incorporating Readmission Rates

Percentage of Respondent Institutions, 2014


One program that is successfully increasing readmission accountability is Miami Cardiac and Vascular Institute (MCVI), which is incorporating readmissions performance into incentives.

In September 2015, MCVI launched a system-wide co-management arrangement for CV specialists across their six hospitals. The contract includes an at-risk bonus based on performance against current value-based goals for the service line—including readmissions metrics for key CV conditions.

A particular benefit of their model is it encourages collaboration across specialties and sites to meet readmissions goals, as everyone must meet their thresholds to receive a bonus. Additionally, MCVI is not solely focusing on conditions currently in the HRRP, but is also building in conditions likely to receive future scrutiny (e.g., PCI, vascular).

Engaging Team to Collaboratively Reach Goals

Source: Miami Cardiac & Vascular Institute, Miami, FL; Cardiovascular Roundtable interviews and analysis.1) Miami Cardiac & Vascular Institute.

MCVI1 Tying Incentives to Readmissions in Co-Management Agreement

Encourages Collaboration to Meet Goals

• All hospitals and their CV specialties must meet metric thresholds to receive bonus

• Incentivizes cross-specialty collaboration to achieve quality, readmission goals

• Created system CV dashboard to regularly monitor performance

Metrics Prepare for Future Mandates

• CV leaders held three meetings per specialty

• Set 100 indicators for performance incentive

• Included medical and procedural readmissions due to increased scrutiny

• Tracking forward-thinking metrics for future inclusion (e.g., outpatient PCI admissions)

Leveraging At-Risk Co-ManagementIncentive to Achieve New Aims

• Launched system-wide CV co-management arrangement in September 2015

• Contract includes at-risk incentive based on service line performance

• Two-year contract with ability to update incentive metrics upon renewal

MCVI’s New CVCo-Management Model

Case in Brief: Miami Cardiac & Vascular Institute

• System-wide CV service line spanning six hospitals across Miami and South Florida; part of Baptist Health South Florida, a not-for-profit system

• In September 2015, rolled out a system-wide co-management contract for the CV service line, replacing the existing co-management contract at one hospital

• Co-management contract includes at-risk bonus incentive based on performance against CV service line dashboard

• Readmissions metrics for key CV conditions are included in the at-risk incentive

• In addition to metrics tracked in the Hospital Readmission Reduction Program, phasing in other CV procedures requiring readmission focus, including admissions following outpatient PCI

• Encourages collaboration across CV specialties to develop best practice strategies for readmissions


To include a metric in the CV co-management performance incentive, MCVI must ensure they have sufficient baseline data to set a valid performance threshold. This can either be external national benchmarks as available—such as those existing through the HRRP—or three years of internal data. As a result, they are phasing readmission metrics into the contract based on baseline data availability, while they collect data on other metrics for future inclusion.

For example, as MCVI has been tracking HF, AMI, PCI, and CABG readmissions for several years, they were able include these metrics in the first round of the co-management incentives. Additionally, in 2013 they began tracking readmissions for pacemakers, ICDs, and vascular surgery, and intend to build these into the contract when it is up for renewal after two years. MCVI also hopes to include admissions after outpatient PCI in this second iteration of the contract, as MCVI began tracking it in 2014. During the three-year data collection period, metrics are not tied to incentives. Yet, MCVI still includes that performance on the CV dashboard so everyone can begin working toward their future goals.

While this model is too new to report a quantitative impact, MCVI has already seen greater collaboration across sites and specialties toward building readmission reduction initiatives.

Phasing in Readmission Metrics

Source: Miami Cardiac & Vascular Institute, Miami, FL; Cardiovascular Roundtable interviews and analysis.

1) Permanent pacemaker.2) Lower extremity vascular surgery, AAA surgical repair.

Requiring Three Years of Benchmarks Before Including in Incentives

Establishing a Baseline

AMI

CABG

PPM1 ICD

Vascular Surgery2

Admission After Outpatient PCI

Included as Incentive Metrics

Data Collection

Potential to Add to Incentives

Data Collection

Potential to Add to IncentivesData Collection

Likely Inclusion in Second Round

2012 20172015

Co-management rollout September 1, 2015

Up for renewal and metric update after year 2

Readmissions Metrics:

• If national benchmarks do not exist for a condition, collect three years of internal data before including in incentive

• While not tied to incentives during data collection phase, performance is tracked and shared on CV dashboard

HF

PCI


Appropriate Patient Selection

The final pillar of a foundation for CV procedural excellence is ensuring programs are offering the right care to the right patients.

Societies continue to develop appropriate use criteria to support this imperative alongside tools to encourage use at the point of care (e.g., phone apps). The Cardiovascular Roundtable offers a compendium of links to the latest resources in our appropriate use compendium, available here and in the online Appendix.

Element 1: Optimal Treatment Choice

Source: European Society of Cardiology, “Guidelines on Myocardial Revascularization,” http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-revasc-FT.pdf; Cardiovascular Roundtable research and analysis.1) Appropriate use criteria.

AUC Guide Teams in Selecting Optimal Treatment for CV Patients

Tools Support AUC Use at the Point of Care

Appropriate Use Criteria for CV Procedures

Procedure Society AUC1

PCI 2012 AUC for Coronary Revascularization: Focused Update

CABG 2012 AUC for Coronary Revascularization: Focused Update

ICD/CRT 2013 AUC for ICDs and CRT

Peripheral Artery Interventions

2014 SCAI Expert Consensus Statements for Appropriate Use of:

• Aorto-Iliac Arterial Intervention

• Femoral-Popliteal Arterial Intervention

• Infrapopliteal Arterial Intervention

• Renal Artery Stenting

Revascularization AUC online app

iCath Mobile App for appropriate use of diagnostic cath and PCI

ACC appropriate use pocket cards for:

• ICD

• Revascularization

iImplant Mobile Appfor appropriate use of ICD and CRT

Access the complete appropriate use resource compendium in the online Appendix


While appropriate use criteria provide guidance, it ultimately requires specialty expertise to make the right decision for a patient. Therefore, some progressive programs, like Aurora St. Luke’s Medical Center in Wisconsin, are hardwiring multidisciplinary decision making for complex cases.

Although multidisciplinary case conferences have become more prevalent recently for advanced procedures (e.g., TAVR, VAD), CV leaders at Aurora recognized this model was valuable to CV surgery patients more broadly. As a result, in 2008 they developed a high-risk CV surgery case conference. This model begins with first identifying appropriate patients using Aurora’s homegrown mortality risk tool, embedded into the pre-op order set. Patients with over 20% mortality risk are automatically referred to the high-risk committee.

The case conference team includes five cardiac surgeons who self-select to participate, in addition to other specialists brought in to address the patient’s comorbidities (e.g., interventionalists, nephrologists). At least two cardiac surgeons and two additional specialists must participate in each case review. During the case conference, the team decides if surgery is appropriate, determines pre-op preparation to manage comorbidities, and sets the optimal care plan to reduce the risk of complications.

Hardwiring Multidisciplinary Decision Making

Source: Aurora St. Luke’s Medical Center, Milwaukee, WI; Cardiovascular Roundtable interviews and analysis.

1) Note: For more examples of CV high-risk case conferences, please see The Blueprint for CV Care Management.

Aurora’s High-Risk CV Surgery Committee Ensures Appropriate Care Plan

Multidisciplinary CV SurgeryCommittee Reviews High-Risk Cases

• 5 cardiac surgeons

• Specialists as needed (e.g., HF specialist, nephrologist, hematologist, interventionalist, anesthesiologist)

• At least 2 surgeons and 2 additional specialists review each case

Sample Questions Discussed

• Do we need additional diagnostics to fully evaluate the patient?

• Do the risks of surgery outweigh the benefits?

• Would an alternative approach offer improved outcomes at a lower risk?

• Does the patient need additional pre-op preparation to manage comorbidities?

• What pre-, peri-, and post-op care plans can be implemented to reduce risk?

All CV SurgeryCandidates Risk Stratified

Homegrown cardiac surgery mortality risk tool embedded into pre-op order set

Ordering surgeon calculates risk score for each CV surgery candidate

Patients with mortality risk >20% automatically referred to high-risk committee

Case in Brief: Aurora St. Luke’s Medical Center

• Flagship hospital of 14-hospital health system in Milwaukee, Wisconsin

• Performs over 1,400 open heart surgeries per year

• In 2008, the CV program created a multidisciplinary team to evaluate all high-risk surgical candidates

• All patients scheduled for CV surgery (e.g., CABG, aortic valve replacement) are risk stratified; very high-risk patients (>20% mortality risk) are referred to the multidisciplinary committee for immediate review

• Team collaborates with patient’s surgeon to verify appropriateness and timing of surgery, provide recommendations on additional testing, and discuss optimal care strategies before, during, and after operation

• Collaborative approach reduced cardiac surgical mortality, complication rate, and unnecessary procedures


1) Pre-high risk process (1/1/2005—11/30/2008) vs. post-high risk process (1/1/2009—6/30/2014).

The CV physician champion spearheading this initiative cited a few critical factors for their success. First, rapid activation of the case conference and turnaround of care recommendations. A dedicated pager alerts the committee of new cases, which must be reviewed within 12 hours via virtual conference.

To minimize the burden on the physicians, they rotate the team lead who is responsible for case intake, leading the discussion, and communicating the results to the referring physician. Documentation is also critical, and they incorporate results directly into the patient chart to ensure pre- and post-op care pathways are executed.

The high-risk CV surgery committee has proven to be a successful model for Aurora. The committee reviews an average of seven cases per month, and physicians are eager to refer their high-risk patients given the emphasis on collaboration and peer input.

Following implementation of the conference, Aurora has seen a 39% decrease in mortality rates for high-risk cardiac surgery patients. CV leaders feel the process has also contributed to the program achieving a three-star STS rating for their CABG and valve programs. Aurora’s experience demonstrates how a hardwired process for selecting appropriate, personalized care pathways can improve outcomes for CV patients.

Identifying Critical Factors for Success

Well Worth the Time and Effort

• Results of discussion entered directly in patient chart

• Includes recommended procedure, timing, and care pathways to minimize risk

• Increases referring physician accountability

• Each cardiac surgeon participant takes a turn as the committee lead for a weekly shift

• Accountable for referral intake, alerting team of new cases and facilitating discussion

Rotating Committee Lead

Documentation Standards

• Dedicated pager alerts committee of new cases

• Set service standard that case reviews occur within 12 hours

• Held via virtual conference to expedite review and reduce workflow disruptions

Rapid Activation and Turnaround

• CV quality committee meeting reviews high-risk cardiac surgery data

• Monitors physician adherence to high-risk committee referrals for eligible patients

Quarterly Review

Surgeons View Case Conference As a Valuable Resource

CV Physician ChampionAurora St. Luke’s Medical Center

Contributed to Aurora’s CABG program receiving a 3-star STS ranking in 2013, AVR and AVR/CABG ranking achieved in 2014

Percentage decrease in mortalityrates for high-risk cardiac surgery patients before and after conference implementation1

39%

High-Risk Committee Yielding a Tangible Impact on CV Surgery Quality

Average number of cases reviewed per month in 20157“Not only did the pre-op review

reduce mortality to below-expected values in very high-risk patients, but spin-off benefits included greater collaboration among cardiologists, surgeons, and other specialists. By the second year of the program surgeons were voluntarily referring even non-high-risk cases for peer input.”

Source: Aurora St. Luke’s Medical Center, Milwaukee, WI; Cardiovascular Roundtable interviews and analysis.


Beyond initial patient and procedure selection, a personalized, risk-tailored approach is incredibly valuable throughout the care pathway. Leveraging risk stratification to tailor care management decisions can improve both quality of care and resource efficiency. To help members take advantage of this opportunity, the Cardiovascular Roundtable has compiled a compendium of risk stratification tools (available in the online Appendix) which can be used to target procedural patient care management across the continuum.

Additionally, programs should heed three key lessons for optimizing risk stratification. First, perform it as early as possible in care, preferably at admission. Second, incorporate psychosocial factors that are likely to increase the readmission risk. Finally, customize care to the patient through risk-based care protocols.

These three lessons are reviewed further in the Cardiovascular Roundtable publication “Blueprint for CV Care Management.”

Element 2: Risk-Tailored Care Pathways


Targeting Resources Toward Patients in Greatest Need

Perform risk assessment as far upstream as possible and repeat throughout the continuum

Access the complete Risk Stratification Tool Compendium in the online Appendix

Three Key Opportunities to Advance Risk Stratification

1

2

3

Incorporate psychosocial and clinical risk factors

Tailor resources (e.g., care coordinators, follow-up phone calls) to individual risk profile

A Well-Researched Terrain

The Cardiovascular Roundtable study Blueprint for CV Care Management provides best practices to optimize risk stratification

Several Risk Tools Available for CV Procedures


Key Takeaways

Use a data-driven approach to identify the greatest opportunities for quality improvement, and focus your efforts on the most impactful strategies.

Action Steps

• Compare performance against external benchmarks to identify opportunities for improvement.

• Perform an internal analysis of recent readmissions to identify key root causes.

• Include hospital and physician-level readmissions on your dashboard to keep a pulse on progress.

Build a high-caliber procedural team by providing opportunities for physicians, nurses, and staff to maintain competency and by building a cohesive team structure.

Action Steps

• Make sure your program can sustain the procedural volumes your clinicians need to maintain competency—if you cannot, partner with other institutions so they can perform additional cases.

• Extend the care team beyond the performing physician to include related specialists and experienced CV OR/cath lab nurses and staff.

• Embed key quality and readmission metrics into incentives to build accountability.

Ensure appropriate selection of both initial procedures and ongoing readmission reduction strategies.

Action Steps

• Encourage use of appropriate use criteria and risk scores to select the right therapy.

• Develop a multidisciplinary case conference to review all high-risk cases.

• Use risk stratification tools to target readmission reduction interventions by patient risk throughout their care pathway.


Chapter 1 reviewed several imperatives for developing a quality infrastructure for a CV procedural program,

which provides the necessary foundation for implementing successful readmission reduction efforts across the

continuum. Below are key action steps for CV programs to achieve this goal.

Build a Foundation for CV Procedural Excellence

VV

V


Tools to Support Your Efforts

Risk Stratification Tool Compendium for Procedural Readmissions

STS Quality Performance Measures for CABG

PCI Performance Dashboard

AHA Scientific Statement: Patient Safety in the Cardiac OR—Human Factors and Teamwork

Cardiac SurgeryQuality Dashboard

Hospital Benchmark Generator

CV Appropriate Use Resource Compendium

Implementation Resources to Build a Foundationfor CV Procedural Excellence

The Cardiovascular Roundtable has collected several resources from other hospitals, societies, and literature

that will help programs carry out the aforementioned action steps and implement the strategies discussed in

this chapter at their own institution. These resources are outlined below and available in the online Appendix.

Access these resources and more in the online Appendix


Lesson 1: Reduce Risk of Post-Procedure Complications

Lesson 2: Coordinate Care Across Patient Recovery


Chapter 2


While institutions across the country recognize the importance of readmission reduction efforts, few CV programs have yet established a strategy to reduce unnecessary procedural readmissions. However, there are three programs identified in the course of this research that have implemented exemplary strategies for reducing procedural readmissions.

The first institution is New Hanover Regional Medical Center, a teaching hospital in North Carolina introduced in the previous chapter with its readmissions root cause analysis. Next, Carolinas HealthCare, a teaching system across the Carolinas including the Sanger Heart and Vascular Institute. Finally, Nebraska Methodist Hospital, a community hospital in Omaha.

Each program has developed deliberate, comprehensive, cross-continuum approaches that are data-driven, multidisciplinary, and resource-efficient. While all three programs have a unique approach to reducing procedural readmissions, each program has achieved a significant decrease in readmissions as a result of their efforts. The remainder of this publication will explore the comprehensive approaches to reducing procedural readmissions at each of these three institutions.

Identifying Three Top-Performing Programs

Source: New Hanover Regional Medical Center, Wilmington, NC; Nebraska Methodist Hospital, Omaha, NE; Carolinas HealthCare System, Charlotte, NC; Cardiovascular Roundtable interviews and analysis.1) Across all three CT surgery programs.

Each Implementing a Comprehensive Procedural Readmissions Strategy

Criteria for Case Selection

Have CV procedural readmission reduction strategies that are:

Cohesive acrossthe continuum

Multidisciplinary

Resource-efficient (e.g., tailored by patient risk)

Integrated with existing care coordination efforts

Successful, with demonstrable outcomes

Data driven

New Hanover Regional Medical Center

• 650-bed teaching hospital in Wilmington, North Carolina

• ~550 open heart cases annually, including 310 CABG

• Launched cardiac surgery readmission initiative in October 2014

• Decreased 30-day same-site CABG readmissions from 10.0% (CY 2014) to 6.9% (CY 2015 to date)

Nebraska Methodist Hospital

• 423-bed community hospital in Omaha, Nebraska

• ~250 open heart cases annually

• Began cardiac surgery readmissions initiative in December 2013

• Decreased 30-day isolated CABG readmissions (same-system) from 10.1% in 2011 to 4.5% as of July 2015

Carolinas HealthCare System

• System across North and South Carolina; three hospitals in Charlotte region part of Sanger Heart & Vascular Institute

• ~1,250 open heart cases annually

• System CABG readmissions initiative began in Fall 2014

• Decreased 30-day, isolated CABG readmissions to any site from 15.3% (Q2 2014) to 5.8% (Q2 2015)1




Program in BriefDescription: 650-bed teaching hospital in Wilmington, North Carolina

CV Physician Affiliation: CV surgeons independent but affiliated through a professional services agreement (PSA)

Procedural Volumes: ~550 open heart cases annually, including 310 CABG

Background on Readmissions Initiative:

• In Spring 2014, New Hanover formed a hospital-wide readmission reduction committee focused on conditions included in the HRRP (HF, AMI, pneumonia, COPD, THA/TKA, CABG)

• In October 2014, the CV service line launched a cardiac surgery-specific readmission reduction initiative and a committee to spearhead the initiative

• Committee meets monthly to review cardiac surgery dashboard and progress on targeted readmission reduction initiatives

Key Stakeholders Involved: Cardiac surgery readmission committee includes VP of cardiac services, CV network director, cardiac surgeons, cardiologists, ICU nurse lead, CV floor nurse lead, case managers, CV surgery educators, as well as representatives from home health, pharmacy, community paramedics program, and finance department

Key Procedural Readmission Reduction Strategies:

Conducting data-driven opportunity identification:

• Internal root cause analysis to identify top three areas of focus for CABG readmission reduction

• Workplans to strategically address each root cause and assign accountability to develop and carry out targeted strategies

• 30-day readmissions metrics for CABG, valve, and CABG + valve included on monthly cardiac surgery dashboard

Reducing risk of post-procedure complications:

• Standardized evidence-based order sets for post-op cardiac surgery patient management

• Hardwired early extubation for appropriate patients

Enabling patients to self-manage:

• Enhanced patient education delivery: performed early in patient stay, engages family, and focuses on alleviating anxiety

• CV surgery-specific teach-back

• Patient education tools embedded into EMR

• “Roadmap” communication board at the foot of the patient bed includes daily goals, care plan, education, and encourages discussion with the care team

Optimizing the transitional care team:

• Dedicated cardiac surgery pharmacist who performs pre-discharge rounds and med-rec on all cardiac surgery patients and assesses ability to comply with medication regimen

• Coordination between inpatient and outpatient pharmacists to ensure medication plan is carried out correctly

Coordinating with providers delivering ongoing care:

• CV surgery-specific training for select home health nurses who perform at least one home visit for all CABG patients

• Expanded community paramedics program to visit high-risk CABG patients at home to avoid unnecessary ED visits

Preventing unnecessary admissions from the ED:

• Expanded ED chest pain unit to broader CV observation unit to address key drivers of unnecessary CV readmission

• Short-stay protocols for HF, chest pain, AFib, syncope (drivers of post-CABG readmissions)

• EMR alert notifies ED physicians if a CABG patient returns to ED within 30 days, triggers short-stay protocols if appropriate

Impact of initiatives: Decreased 30-day CABG readmissions (same-site) from 10.0% (CY 2014) to 6.9% (CY 2015 as of October 2015)


Carolinas HealthCare System, Sanger Heart & Vascular Institute

Source: Carolinas HealthCare System, Charlotte, NC; Cardiovascular Roundtable interviews and analysis.

Program in Brief

Description: Health care system across North and South Carolina, with three hospitals in the Charlotte, NC region that are part of the Sanger Heart & Vascular Institute

CV Physician Affiliation: CV physicians are employed and integrated into leadership throughout the Heart & Vascular Institute

Procedural Volumes: ~1,250 open heart cases annually (CABG, valve, thoracic, aortic, VAD, transplant; excluding general thoracic)


• Launched Cardiac Surgery Continuum of Care Committee in Fall 2014 to oversee system-wide readmission reduction efforts

• Meet monthly in person and through video conference

• Each of the three SHVI hospitals with a cardiac surgery program has a workgroup to enact initiatives developed by the system Committee

Key Stakeholders Involved: Committee includes ~20 participants from across the continuum (e.g., cardiac rehab, home health, ambulatory clinics, inpatient units)


Reducing risk of post-procedure complications:

• Retrospective analysis of CT surgery readmissions to identify key root causes

• Risk stratification of all cardiac surgery patients for risk of renal failure, stroke, and pulmonary complication

• High-risk inpatient care pathways for aforementioned complications included on pocket cards for surgery and post-op care team

• Hardwired fast-track extubation (<6 hours) through setting extubation goals at ICU admission and nurse-led weaning protocol

• Real-time monitoring and feedback of adherence to evidence-based ICU protocols (high-risk pathways, early extubation)

Coordinating care across patient recovery:

• Homegrown CT surgery readmission assessment performed for all patients upon admission to cardiac floor

• Risk score displayed in patient chart and discussed during daily rounds among care team and patients/family


• Patient-friendly cardiac surgery post-discharge recovery guide simplifies complex discharge instructions for patients, clearly displaying most important steps in transition of care post-discharge

• Post-discharge education front-loaded to begin prior to surgery


• Acute Illness Management (AIM) team provides intense transitional care support for highest risk, comorbid patients to transition them to long-term physician care management

• AIM trigger built into CV care pathways (e.g., ACS/MI) to ensure high-risk patients are referred

Maximizing transition clinics for high-risk procedural patients:

• “Heart Success” high-risk transition clinic expanded from just HF to include CABG and valve patients, with intention to expand to COPD and AMI in 2016

• Cardiac surgery care pathway for Heart Success clinic

Ensuring appropriate cardiac rehab utilization:

• Automatic referral to cardiac rehab for all CV procedural patients

• Monthly review of cardiac rehab referral adherence and patient attendance conducted to target efforts to improve attendance

Coordinating with providers delivering ongoing care:

• Cross-continuum ACS pathway used by cardiologists and PCPs, reducing care variation for MI and interventional patients

• Privileges for CV APPs and cardiac surgeons to round on cardiac surgery patients in inpatient cardiac rehab

Impact of initiatives: Decreased rolling year 30-day isolated CABG readmissions rate to any site from 15.3% in Q2 2014 to 5.8% in Q2 2015; HF year-to-date readmission rate (same-site, Carolinas Medical Center) decreased from 17.0% in 2010 to 11.7% in 2015



Source: Nebraska Methodist Hospital, Omaha, NE; Cardiovascular Roundtable interviews and analysis.

Program in Brief

Description: 423-bed community hospital in Omaha, Nebraska

CV Physician Affiliation: Two independent cardiac surgeons perform procedures at Methodist

Procedural Volumes: 245 open heart surgeries in 2014; 251 from January 2015 September 2015


• Began targeted focus on cardiac surgery readmission reduction in December 2013

• Multidisciplinary team reviews outcomes every other month and targets opportunities for improvement

Key Stakeholders Involved: Multidisciplinary team including CV leadership, PI, APRN leadership, representatives from anesthesia, universal bed and surgery nurses, care management, respiratory, lab, and radiology.


Conducting data-driven opportunity identification:

• Quarterly review of all readmitted patients to identify trends and opportunities for improvement

• Send data collection form to surgeon offices to get accurate follow-up data and readmission rates across the health system

Coordinating care across patient recovery:

• Inpatient care coordinator-initiated early discharge planning for all patients, ensuring care team and family understand what is necessary for effective recovery and discharge

• Multidisciplinary daily rounds for cardiac surgery patients to target early identification of complications and barriers to discharge

• Standardized shift-to-shift bedside handoffs

• Universal bed model for all open heart patients (CABG, valve, balloon pump) with consistent care team across recovery


• Customized cardiac surgery discharge education and instructions, provided beginning day one of post-op recovery

• Cardiac surgery-specific teach-back scripting used for all outreach to post-op patients, across all care sites (e.g., inpatient units, follow-up phone calls, cardiac rehab, outpatient clinics)


• Follow-up appointments for cardiac surgery patients: NP visit within 72 hours; cardiac rehab within 72 hours; PCP visit in one week; cardiac surgeon in 3-4 weeks; cardiology in 4-6 weeks

• Partnership with hospital-wide care management initiatives to ensure care coordination strategies are integrated and consistent, and reduce unnecessary duplication of efforts

• “Health Services” RN team (managed out of care management department) provide follow-up calls to CABG, CHF, and AMI patients post-discharge to monitor recovery

• Health Services team intakes all calls from patients and triages them to appropriate provider (including the NP navigator) based on urgency and severity

• Cardiac Surgery NP navigator provides 72-hour follow-up visit with all cardiac surgery patients, coordinating between inpatient care team and outpatient clinic

• NP navigator available for urgent visits as scheduled by Health Services team, as necessary

Ensuring appropriate cardiac rehab utilization:

• Automatic cardiac rehab referrals for all cardiac surgery and interventional patients

• Pre-certification for cardiac rehab completed in hospital pre-discharge

• Cardiac rehab prompts embedded into scripting for Health Services follow-up calls

Preventing unnecessary admissions from the ED:

• ED case manager identifies readmitted patients presenting in the ED and triages to most appropriate care setting

• ED care pathway for post-CABG/valve ensures case manager contacts cardiac surgery NP navigator before admitting

Impact of initiatives: Rolling 12-month 30-day CABG readmission rate 4.5% as of July 2015, compared to 10.1% in 2011


Lesson 1

Source: Hannan EL, et al., “30-Day Readmissions After CABG in New York State,” JACC: Cardiovascular Interventions, 2011, 4:569-576; Iribarne A, et al., “Readmissions After Cardiac Surgery,” Annals of Thoracic Surgery, 98:1274-1280, 2014; Cardiovascular Roundtable research and analysis.

1) Representative study.2) MS-DRG 291: Heart failure and shock with MCC.3) MS-DRG 233: Coronary bypass with cath with MCC.4) Superficial sternotomy infections (chest) and deep sternotomy infections (chest).

Compared to existing approaches to reduce HF and AMI readmissions, procedural readmission reduction introduces new complexities. In fact, 27% of CABG readmissions are caused by infections or complications from the surgery or recovery. These are factors not considered with medical conditions (e.g., heart failure). Additionally, procedural patients spend more time in the hospital, increasing the opportunities for a coordination breakdown. Given the complications with procedural patients, is it therefore critical to optimize inpatient care to prevent these incidents. The first step to doing so is hardwiring strategies to reduce risk of infection and complication.

Two complications that require particular focus in cardiac surgery readmission efforts are primary surgical site infections and pneumonia, which together account for 58% of infection-related cardiac surgery readmissions. While clinical literature provides clear tactics to address each of these, studies demonstrate that compliance with these measures remains poor.

Programs have a distinct opportunity to reduce post-procedure complications through developing risk-based recovery pathways, fast-tracking extubation, expediting ICU discharge, and monitoring guideline adherence.

Complexities of Procedure and Recovery Present New Challenges

Reduce Risk of Post-Procedure Complications

A New Hurdle in the Fight Against Readmissions

Identifying the Key Culprits

Infections or Procedural

Complications

Primary Reason for30-Day CABG Readmission1

Percentage of Patients Readmitted

Longer LOS for Surgery Patients, More Time in Critical Care

5.1 Days 34%

92%

LOS(50th Percentile)

Heart Failure(MS-DRG 291)

CABG(MS-DRG 233)

27%

Complications Causing Cardiac Surgery Readmissions

Key Opportunities to Reduce Risk of Post-Procedure Complications

Use of Respiratory Bundling Strategies

• Early ambulation

• Ventilator bundles

• Respiratory physiotherapy

Fast-track extubationas appropriate

Monitor adherenceto guidelines

Expeditedischarge from the ICU

Pneumonia

Together account for 58%

of infection-related cardiac

surgery readmissions

Evidence-Based RiskReduction Strategies

Primary surgical site infections4

Greater Adherence to Processes of Care

• Attention to skin preparation

• Appropriate timing and dosing of antibiotics

• Discontinuation of antibiotics after 24 hours

• Hand washing

Develop risk-based recovery care pathways

11.1 Days

Percentage of Stay in ICU/CCU (50th Percentile)



As our first example, Carolinas HealthCare System has developed a data-driven strategy to effectively minimize risk of post-procedural complications through risk-based care pathways

CV surgery leaders are diligent about reviewing their STS dataat biweekly, system-wide performance improvement meetings to identify areas on which to focus. Across these meetings, they recognized an opportunity to standardize evidence-based care pathways across the CV surgery program in order to better manage risk of complications. They targeted three complications that have the greatest impact in CV surgery and are also NQF-endorsed: renal failure, pulmonary complications, and stroke.

After choosing the complications to target, the committee developed a process to identify and tailor care for patients at high risk of each complication. They paired risk scores with each of the conditions, then created distinct high-risk care protocols. These protocols are printed on pocket cards for the care teams to use.

Internal Review IDs Primary Post-Op Complications

1) Sanger Heart and Vascular Institute.2) Performance improvement.

Team Targets Key Opportunities to Mitigate Risk

Honing in onKey CT Surgery Complications

• SHVI1 PI2 Committee reviews system’s STS data biweekly to target areas to advance quality

• Identified a need to develop consistent care pathways for patients at high risk of CV surgery complications

• Prioritized NQF-endorsed measures

1

2

3

Renal Failure

Stroke

Pulmonary Complication


Risk Tools Inform Use of Carolinas’ High-Risk CV Surgery Pathways

STS Risk Calculator

Calculates a predicted risk score for CT surgery patients in each of the following events:

• Mortality

• Morbidity

• Long/short LOS

• Permanent stroke

• Prolonged ventilation

• Deep sternal wound infection

• Renal failure

• Reoperation

EuroSCORE II

Calculates predicted operative mortality for patients undergoing cardiac surgery; used in patients ineligible for STS Risk Calculator

Katz Index of Independence in Activities of Daily Living

Assesses ability to perform tasks necessary for daily living, incorporating psychosocial factors

Homegrown Renal Risk Score

Developed through internal analysis of SHVI CV surgery patients

• System-level PI Committee created evidence-based protocols for patients at high risk of each complication

• Quality working groups at each SHVI hospital responsible for rolling out protocols at their CT surgery programs

Developed High-Risk Care Pathways

Using Data toInform Strategy



Carolinas’ leaders indicated the importance of initiating these care protocols as early as possible for high-risk patients. Therefore, a cardiac surgery APP risk stratifies each patient as soon as they are identified as surgical candidates.

The protocols outline how caregivers should adjust care at each stage: pre-, intra-, and post-procedure. They also outline accountability for tasks at each stage, how to execute successful handoffs, and when to perform additional risk analysis.

The pathways are clearly outlined on easy-to-use pocket cards to ensure they are used by the entire care team.

Risk Stratification Informs Inpatient Care Plan

1) Advanced practice provider.

High-Risk Care Pathways Established for Each Key Complication

Risk scores calculated upon cardiac surgery patient identification to initiate care protocols

Cardiac surgery APP1

performs risk analysis and CT surgeon confirmsresult

• Unique care protocols for renal failure, stroke, and pulmonary complication risk mitigation

• Outline pre-, intra- and post-op care plan

• Each is clearly detailed on three-page pocket cards for care teams

Care team follows care pathways for high-risk patients across inpatient care

Sample Complication-Specific Care Pathway

Risk Stratification Triggers Protocol Use

SHVI’s pulmonary, renal, and stroke risk mitigation pathways available in the online Appendix




Carolinas has also highlighted the effectiveness of hardwiring protocols for early extubation—or weaning a patient off ventilation within six hours post-surgery—in optimizing post-procedural outcomes.

There is strong evidence to support this assertion that, if appropriate, early extubation reduces the risk of complications (e.g., pneumonia). However, given the many competing priorities nurses face in a critical care setting, early extubation of stable patients is not always top of mind.

Therefore, Carolinas has implemented safeguards to ensure patients are extubated appropriately. First, the physician and care team set time goals immediately following surgery: under six hours is the default, adjusted based on risk.

They also have empowered ICU nurses to extubate without direct physician oversight using a detailed weaning algorithm.

Finally, Carolinas tracks early extubation rates in their cardiac surgery ICU database, which CV leaders review weekly to increase accountability.

Drilling Down on Fast-Track ExtubationKey Strategies Ensure Appropriate Timing to Reduce Complication Risk

Extubation Goal Set at ICU Admission

• Physician, nurse, and respiratory therapist determine ideal timing

• Early extubation within six hours is the default, adjusted based on risk

• Physician writes order, noting criteria that must be met prior to weaning

Weaning Protocol for ICU Nurses

• Detailed algorithm enables nurses to extubate without direct physician oversight

• Includes consult triggers to inform physicians early of complications

Monitor Real-Time Database

• Cardiac surgery ICU database tracks early extubation rates

• ICU charge nurse responsible for real-time data entry

• Review performance reports weekly




Carolinas’ data-driven, evidence-based strategy for post-operative care has proven to be very successful. On average, 80% of patients are extubated within their six hour goal, and ICU length of stay has decreased 0.5 days for CABG patients. The care pathways are also undoubtedly contributing to Carolinas’ low readmission rates.

Approach Yielding Tangible Results

1) Results are for isolated CABG patients at Carolinas Medical Center only.

Regular Monitoring Supports Adherence to New ICU Protocols

Optimizing Post-Op Care for CABG Patients1

Holding Caregivers Accountable

Patients extubatedwithin goal of 6 hours

80%

SHVI tracks real-time compliance to protocols using Scantron checklist of care pathways

Decrease in mean ICU LOS for isolated CABG

0.5 daysDecrease in mean total LOS for isolated CABG (11.6 days in 2012 to 9.2 days in 2013)

2.4 days

Checklist travels with patient; clinician checks off as each task is completed and scans after discharge

Review clinician-level reports at monthly quality meetings toencourage compliance

Added weaning algorithm, cardiac surgery risk stratification, and use of new post-op care pathways to checklist



Lesson 2

Coordinate Care Across Patient Recovery

While it is important to mitigate the risk of clinical complications, operational risk factors inherent in post-procedure recovery must also be addressed.

Over the course of a typical patient pathway for a complex procedure, there are several opportunities for mis-communication or loss of data. It is therefore critical to coordinate care across the entire team throughout recovery.

This lesson identifies four key opportunities to do so. First, communicate each patient’s risk level to the care team to distinguish high-risk patients. Second, hardwire effective, consistent handoffs. Third, implement multidisciplinary rounds to ensure input from the range of providers involved in care. Finally, consider a universal bed unit model to further ensure coordinated care.

A Complex Choreography

Source: Institute for Healthcare Improvement, “Improving Transitions in Hospital Care,” www.ihi.org; Cardiovascular Roundtable research and analysis.

1) Unanticipated event in a health care setting resulting in death or serious physical or psychological injury to a patient.

Surgical Patient Recovery Involving Multiple Units, Caregivers

24 handoffs occurduring average 4.8 day stay

60% of sentinel events1 caused by communication failures

Typical Inpatient Care Pathway for a Cardiac Surgery Patient

Surgery ICU Step-down unit Cardiac unit Discharge

Numerous Caregivers Across Stages and Shifts

• Cardiac surgeon

• Anesthesiologist

• OR nurses

• Intensivist

• ICU nurses

• Educator

• Dietician

• Social worker

• Cardiologist

• Hospitalists

• Care managers

• Cardiac floor nurses

• Nurse navigator

• Pharmacist

• Discharge nurse

Key Opportunities to Coordinate Care Across Patient Recovery

Execute effective handoffs

Evaluate a universalbed model

Implement multidisciplinary rounds

Communicate patient risk level to the care team



One of the first steps institutions can take to coordinate care across patient recovery is to communicate patient risk levels to the care team.

As discussed in Lesson 1, Carolinas HealthCare implemented high-risk ICU care pathways to tailor immediate post-operative care to patient risk.

In addition to this initiative, CV leaders also wanted to assess risk of readmission based on what occurs during surgery and ICU recovery, as well as due to preexisting conditions. Therefore, they developed a homegrown CT surgery readmission risk assessment—based on their own patient population—for use after discharge from the ICU.

The risk tool is used when a patient is admitted to the cardiac floor post-ICU. The presence of any one of the outlined criteria elevates patient risk. This risk level is entered into the patient chart to ensure it remains front and center to the care team during daily rounds and is incorporated into decision making during recovery and discharge. Importantly, they also discuss this risk level with the patient and family to encourage shared decision making and patient engagement.

Readmission Risk Front and Center Across Recovery

Source: Carolinas HealthCare System, Charlotte, NC; Cardiovascular Roundtable interviews and analysis.1) Predictive analytics software.

Risk Score Incorporated into Care Team Rounds to Tailor Decisions

SHVI CT Surgery Readmission Risk Assessment

Completed UponAdmission to Cardiac Floor

• APP, surgeon complete multidisciplinary assessment

• Accounts for complications that may have arisen in ICU(e.g., post-op AFib)

Top of Mind for the Care Team

• Surgeons requested risk score displayed in patient chart to discuss during daily surgeon rounds

• Ensures consistent level of care; team tailors care plan appropriately

• Communicate risk to patients and family

Meets One or More of the Following:

Post-operative AFib

Reduced EF/HF (<40%) or on a LifeVest

Uncontrolled diabetes (HgbA1C >8; average inpatient glucose >180; change in diabetic medications)

Pleural effusion (moderate or greater)

Wound concerns (e.g., red, open, or draining; or sent home with specific wound management instructions beyond standard of care)

Patient refuses home health

High/very high Predixion1 Score

Medium/high GRACE Score (only if initial admission was for an Acute MI)

Other Factors to Take Into Consideration:

Post-operative LOS >7 Days

ICU LOS >3 Days

Age >75

Criteria chosen through internal analysis of readmissions

Any one of the criteria places patient in high-risk category



In addition to risk stratification, there are several other strategies that elevate post-operative coordination, as illustrated through Nebraska Methodist Hospital’s multipronged approach.

First, the team implemented multidisciplinary daily rounds for cardiac surgery patients. These rounds keep the entire team updated on patient risk and barriers to discharge and ensure a consistent care plan.

CV leaders also introduced early discharge planning. The CV surgeon and NP set a discharge goal at patient admission to the floor and communicate this to the care team, the patient, and family, so everyone can drive toward appropriate discharge.

Third, the CV program standardized patient handoffs. The care team uses a template report to ensure key details are not lost and perform handoffs at the bedside to engage patients and the family.

Finally, the CV surgery program has established a universal bed model, also known as an “acuity-adaptable” unit. In this model, patients stay in one unit bed that “adapts” to their acuity as they recover—both in nursing ratio and protocols—rather than transferring from ICU to step-down unit to the main floor.

Multi Pronged Approach to Coordinating Team CareSeveral Strategies Optimizing Cardiac Surgery Patient Recovery

Standardized Bedside Handoffs• Created shift-to-shift handoff

form specific to cardiac surgery

• Ensures all critical data is shared

• Nurses complete bedside to engage patient and family in discussion

Universal Bed Model• Created cardiac surgery

universal bed unit in 2013

• Patients remain in same unit for entire post-op recovery, versus transferring between ICU, step-down, and main floor

• Goal is to streamline care throughout recovery, as one team remains with patient throughout their stay

Multidisciplinary Daily Rounds• NP, care coordinator, social

worker, staff nurse, chaplain, dietician, and discharge planner

• Occur at 11 a.m., in middle ofshift so NP is prepared todiscuss patient status updates

• Discuss barriers to discharge and risk

Early Discharge Planning• Set discharge goal at admission

to floor and communicate to entire team to drive toward discharge

• Cardiac surgery care coordinator begins discussing discharge with patient and family on day one of recovery

• Ensures family ready to take patient home at discharge

Access CV handoff report in the online Appendix




In 2013, Methodist piloted its universal bed unit within the cardiac care floor. The unit consists of private rooms designed to accommodate patients and their family from immediately post-surgery to discharge. The unit is staffed with between a 1:1 to 1:4 nurse to patient ratio, flexing based on patient acuity and stage post-surgery. All the NPs staffed to the unit are CV-trained and the majority certified in cardiac critical care.

The unit is currently only open to heart surgery patients (e.g., CABG, valve, balloon pumps). However, based on the success of the pilot, the unit has since expanded from eight to 18 beds, and CV leaders are considering expanding to thoracic surgery patients.

Universal Bed Model Enhancing Coordination

1) Respiratory therapists.2) ACCN Acute/Critical Care Cardiac Surgery Subspecialty Certification.

Removes Barriers to Continuity Brought on by Unit Transitions

Cardiac SurgeryUniversal Bed Unit


Facility

• Within cardiac care unit

• Began with 8 beds in 2013

• Added 10 beds in August 2015

• Patient stays in same private room throughout stay

Staffing

Patients Care Pathway

• One CV NP dedicated to unit, with support from CV RNs, charge RN and RT1

• 1:1-4 RN to patient ratio basedon census and stage in recovery

• All RNs CV-trained, many CSC2 certified

• CT surgery and cardiology are co-medical directors

• Patients admitted immediately following surgery

• Consistent care team throughout stay

• Emphasize education delivery

• Open exclusively to open heart surgery patients (CABG, valve, balloon pump)

• Considering expanding tothoracic surgery



Nebraska Methodist, as well as other experts in the field, have credited this model as part of their success in reducing cardiac surgery readmissions. They also have observed several other positive results from this model, including greater care coordination, reduced variation, and lower length-of-stay. Additionally, patients and families appreciate the model, both for convenience and comfort, as well as the ability to build a stronger relationship with their care team.

As evidence of this, a year and a half after implementation, Methodist has surpassed many key STS CABG national benchmarks, including post-op complications, mortality, and readmissions.

It’s important to note that the universal bed model may not be an optimal model for every institution given the costs involved in facility redesign, requisite cross-training, and new protocols. However, if implemented correctly and in the appropriate circumstances, a universal bed model can be a successful strategy for optimizing cardiac surgery patient recovery.

Improving Quality of Recovery Care

Source: Nebraska Methodist Hospital, Omaha, NE; Cardiovascular Roundtable interviews and analysis.1) Universal bed unit opened December 2013.

Coordinated Care Reduces Complications, Improves Efficiency

Patient, Family SatisfactionBuild a stronger relationship, trust with caregivers; convenience of one room

Enriched Patient Education Consistent message delivered across stay and tailored to patient progress

Reduced Care VariationDistinct team delivers all cardiac surgery care, facilitating evidence-based protocol implementation

Greater Care Coordination Consistent team reduces risk of miscommunicating care plans

Improved EfficiencyEliminates unit transfers, reducing LOS

Impact of Universal Bed Unit

CABG MetricNational STS Benchmark

NebraskaMethodist

Mean post-op LOS 6.8 days 5.4 days

Mean ventilator time 15.0 hours 5.4 hours

Deep sternal wound infection 0.2% 0%

Post-op AFib 23.2% 14.4%

30-day readmission 9.2% 4.5%

Mortality rate 1.6% 0.9%

Surpassing National Benchmarks

August 2015, Past 12 Months1


Key Takeaways


Action Steps

• Develop risk-based care pathways that span pre-, peri-, and post-procedure care to mitigate risk of common procedural complications.

• Implement protocols that trigger early extubation for appropriate patients to reduce risk of pulmonary complication.

• Expedite ICU discharge to minimize unnecessary time in a critical care setting.

• Monitor clinician adherence to evidence-based guidelines for infection control.

Coordinate care across patient recovery to ensure all caregivers manage against the same cohesive care plan and are aware of patient risk.

Action Steps

• Stratify patients both pre- and post-procedure for risk of readmission, and communicate patient risk level to caregivers across their care pathway.

• Execute effective handoffs between shifts and units by performing bedside and using a standardized form.

• Implement multidisciplinary daily rounds that focus on early identification of complications and barriers to discharge.

• Evaluate creating a universal bed model to enhance care coordination, improve efficiency, and elevate patient satisfaction throughout the patient stay.

Reduce risk of post-procedure complications—as these are among the top causes of procedural readmissions—through optimal inpatient care techniques.


Chapter 2 reviewed several strategies for perfecting inpatient care to improve long-term outcomes, including

reducing risk of post-procedure complications and coordinating care across patient recovery. Below are key

action steps for CV programs to achieve this goal.

VV



The Cardiovascular Roundtable has collected several resources from other hospitals, societies, and literature that

will help programs carry out the aforementioned action steps and implement the strategies discussed in this

chapter at their own institution. These resources are outlined below and available in the online Appendix.


CCU/ICU Utilization Benchmarks

Extubation Fast-Track Criteria

CV BedsideHandoff Report

Guidelines for Antibiotic Use in Cardiac Surgery

Complication Risk Mitigation Pathways for Cardiac Surgery Patients:

• Renal failure

• Stroke

• Pulmonary Complications

CT Surgery Readmission Risk Assessment

Implementation Resources to Perfect Inpatient Care to Improve Long-Term Outcomes

Clinical Practice Guidelines for Cardiac Surgery




Lesson 3: Enable Patients to Self-Manage

Lesson 4: Optimize the Transitional Care Team

Lesson 5: Maximize High-Risk Transition Clinics for Procedural Patients


Chapter 3


While the previous chapter outlined strategies to optimize inpatient care delivery, procedural readmission reduction efforts cannot stop in the inpatient realm. Significant opportunities lie in coordinating care once patients leave the hospital—beginning with the initial transition out of the acute setting.

The term “Beyond Four Walls” —meaning that hospitals can’t limit care efforts to what occurs within their walls—has become a common theme when discussing readmissions reduction efforts. However, while institutions have made positive strides in this regard for heart failure, CV programs are still largely mired in an acute mind-set for procedures.

Yet procedural patients have demanding longitudinal care needs as well, and are particularly vulnerable during the initial transition between the hospital and first physician visit. For example, readmitted patients, on average, return to the hospital six days post-discharge, as patients often struggle to follow complex care instructions, and many post-surgery infections do not manifest until after patients have left the hospital.

Fortunately, many strategies employed for heart failure patient transitions will be just as valuable for procedural patients once adapted to meet their unique needs.

Beyond Four Walls: A New Mind-Set for Procedures

Source: Price JD, et al., “Risk Analysis for Readmission After Coronary Artery Bypass Surgery: Developing a Strategy to Reduce Readmissions,” Journal of the American College of Surgeons, 216, no. 3, (2013): 412-419; Cardiovascular Roundtable research and analysis.

Transitional Care Efforts Must Extend Beyond Heart Failure

Transition Strategies Applicable for Procedural Patients, but Often Underutilized

Hospital Strategy HF Procedural

Risk stratification

Care coordinators

Discharge planning

Follow-up phone calls

Transition clinics

Remote monitoring

High-risk home visits

Patients Typically Targeted in Care Transition Programs

Unlike medical readmissions, CABG readmissions are more often the result of delayed occurrence or recognition of procedural complications. With shorter hospital stays, complications will often be first noted after discharge.”

Patients Particularly Vulnerable Immediately Post-Discharge

6 daysMedian time from CABG patient discharge to readmission

Price JD, et al., Journal of the American College of Surgeons (2013)


Lesson 3

Enable Patients to Self-Manage

One of the first steps institutions can take when building a transitional care strategy for procedural patients is to increase patient engagement. Readmission reduction efforts will be in vain if the patient is not willing and able to self-manage once he or she leaves the hospital.

In fact, there is strong evidence of the impact of effective patient education for procedural patients. A recent study found pre-operative CABG education sessions not only decreased post-operative complications, but also decreased patient anxiety, which is a driver of many unnecessary readmissions.

There are several key opportunities to enable patients to self-manage. First, start education as early as possible in a patient’s care. In each education session, involve family members and caregivers alongside patients. It is also essential to develop clear, patient-friendly education materials to increase comprehension. Finally, tailor discharge instructions based on each individual patient’s needs.

Critical to Engage Procedural Patients in Their Care

Source: Zhang CY, et al., “Impact of Nurse-Initiated Preoperative Education on Postoperative Anxiety Symptoms and Complications After Coronary Artery Bypass Grafting,” Journal of Cardiovascular Nursing, 27, no.1, (2012): 84-88; Cardiovascular Roundtable research and analysis.

1) Deep venous thrombosis or dysrhythmia following surgery. 2) Significant anxiety symptoms >40 after surgery.

Study Demonstrates the Power of Comprehensive Patient Education

Decreases Post-op Complications

Decreases Post-op Level of Anxiety

CABG Education Improving Outcomes

Key Opportunities to Enable Patient Self-Management

Engage family

Begin education as early as possible

Tailor discharge instructions based on patient’s needs

Ensure education materials are easy to understand

45%

15%

ControlGroup

EducationGroup

• Provided CABG education three days pre-surgery

• Included review of pulmonary care techniques, post-op rehab, counseling

55%

5%

ControlGroup

EducationGroup

Percentage of Patientswith CV Complications1

Specialized nurse educator

Study in Brief: Impact of Pre-Op Education on Post-Op Anxiety, Complications After CABG

• 2012 study on the impact of pre-operative education on post-operative anxiety and complications after CABG

• Prospective randomized trial of 40 patients divided into study and control groups; both groups received standard pre-operative and post-operative care

• The study group completed a structured education course by designated nurses three days prior to surgery; course included instruction on pulmonary care techniques, post-operative rehabilitation, and a counseling course

• The education and counseling course significantly reduced post-opcomplications and level of anxiety following CABG

Percentage of Patientswith Anxiety Post-Surgery2



As part of New Hanover’s CABG readmission reduction initiative, leaders prioritized redesigning patient education to better equip patients to self-manage. A key focus has been on enhancing delivery to better encourage comprehension. They now frontload education to begin on the first day of a patient’s stay, provide instruction in smaller portions, and involve family members.

Beyond improving the delivery format, New Hanover also added three new education initiatives. First, they implemented the "teach-back" approach for discharge instructions to ensure comprehension. They also embedded education tools into the EMR to hardwire them into the workflow. Finally, they developed a “roadmap” communication board outlining the patient’s care plan, which is explored in greater depth on the next page.

Redesigning Education for Procedural PatientsCV Surgery Education Restructured to Better Activate Patient, Family

Implementing New Education Tactics

Embedded patient education tools into EMR to ingrain in the workflow and ensure compliance

CABG Readmission Reduction Initiative

Redesign model for delivering cardiac surgery patient education

Cardiac surgery manager and nurses developed new education routine

Start education delivery at the beginning of the patient’s stay

Provide education in smaller modules to increase comprehension

Developed roadmap communication board to keep at foot of patients’ beds

1

2

3

Involve family or caregivers in education as well as patient

Established the teach back method for discharge instructions




New Hanover’s patient roadmap is in the form of a whiteboard at the foot of the patient bed. It outlines key information for patients, family, and the care team, such as the names of the caregivers, the patient’s daily schedule, and goals for discharge. The roadmap also contains a section for patients and family members to write questions to ask during rounds in an effort to increase communication with the care team.

This simple tool engages patients and their family in their care and encourages shared decision making with clinicians. In addition, it keeps the entire care team aligned and coordinated on the patient’s care pathway and discharge goals.

Roadmap Aids Bidirectional CommunicationTool Enhances Patient Understanding of Care Plan Throughout Stay

Benefits of Approach

Engages patient and family in care pathway and improves experience

Encourages shared decision making with clinicians

Ensures entire care team is aware of care plan

Encourages a drive to discharge

Lists care team

Goals for discharge

Details schedule for each day

Physicians, patients, and family write questions and comments on board




While the roadmap communication board builds patient engagement in the overall care plan, New Hanover’s readmission root cause analysis revealed many CV surgery patients need more targeted support to adhere to their medication regimens.

In response, the CV program assigned a dedicated cardiac surgery pharmacist to round on all CABG patients before discharge. The pharmacist performs medication reconciliation (med-rec) and assesses the patient’s ability to comply with the standard medication regimen, adjusting the plan if needed.

The inpatient pharmacist also coordinates with her ambulatory counterpart to help bridge the transition for high-risk patients. This community pharmacist can monitor patient progress, reinforce medication instructions, and join home visits when necessary.

This dedicated cardiac surgery pharmacist has proven very effective in proactively identifying and overcoming barriers to medication adherence for this complex patient population.

Boosting Medication Adherence Pharmacists Provide Added Support for Patients at Risk of Noncompliance

• Dedicated cardiac surgery pharmacist performs pre-discharge rounds, med-rec for all cardiac surgery patients

• Evaluates psychosocial and financial factors

Home Support

Psychosocial Assessment

Risk-Tailored Medication Plan

• Creates specialized medication plan for highest-risk patients

• Accounts for ability to afford, understand, and comply with regimen

• Community pharmacist joins home health nurse or community paramedic home visits for complex patients requiring additional medication resources

Cross-Continuum Coordination

• Discharge pharmacist communicates medication plan to NHRMC community pharmacist

• Ensure patient is able to access prescriptions, adhere to plan

Factors Evaluated During Medication Planning

Family, social support

Financial situation

Access to pharmacy

Health literacy




Nebraska Methodist Hospital has also recognized the importance of patient education and enabling procedural patients to self-manage following discharge.

A key area of focus for Methodist has been on the teach-back method, which is a technique in which a clinician provides patient education then asks the patient to “teach back” what was just explained to ensure comprehension and reinforce the teaching. Teach-back has become widespread for heart failure, but Methodist saw the value for cardiac surgery patients as well and developed specific teach-back scripting for this population.

What Methodist has found particularly effective is that all providers use the same scripting across the continuum (e.g., the inpatient team, care managers, nurses that perform follow-up calls, outpatient clinic providers). This ensures the patients receive consistent messaging throughout the care pathway.

Standardizing Education Delivery


CV Surgery Teach Back Scripting Ensures Consistency Across Care

Use same scripting across sites for consistent messaging (e.g., CV unit, follow-up phone calls, cardiac rehab)

Created standard teach back scripting for cardiac surgery

Incorporated into general training for heart nurses

Key Elements of Education Design

Reinforces learning to patients throughout stay, encourages comprehension

Scripting for CV Surgery Patients

Cardiac Surgery Teach-Back

Who is the point of contact after you are discharged?

• Health Services Nurse: 555-123-4567

• M-F 7:30 am – 7:00 pm

• Weekends & Holidays 8:00 am-4:30 pm

• Call 555-123-4444 after Health Services hours

What signs and symptoms should be reported?

• Weight gain (2lbs in 1 day or 5lbs in a week)

• Shortness of breath

• Fever >100.0º

• Uncontrolled pain

Activity Guidelines

• No heavy lifting >10 lbs. for 8 weeks

• No driving for minimum of 2 weeks or longer if takingpain medications

• Okay to shower

Cardiac surgery teach-back scripting available on the online Appendix



As a final example of improving patient ability to self-manage, Carolinas HealthCare is focusing on streamlining post-discharge education as part of its readmission reduction strategy.

CV leaders at Carolinas recognized that discharge instructions were so complex, many patients missed important follow-up steps. Therefore, they worked with their Patient and Family Advisory Council to refine post-discharge instructions into a patient-friendly heart surgery recovery guide that clearly outlines important next steps once they are home in a checklist format. The recovery guide details when to schedule follow-up appointments, what to expect post-discharge, and questions to ask on follow-up calls. The care team explains the guide before discharge to help ensure comprehension.

Each of the previous approaches effectively enhance the ability of procedural patients to adhere to post-discharge instructions and manage their care to reduce preventable readmissions.

Guiding Patient Self-Management Post-Discharge


Recovery Guide Distills Key Action Items from Complex Instructions

Key Components of Recovery Guide

Patient and Family Advisory Council advised on recoveryguide creation to ensure it was patient friendly

Includes care team’sdirect contact information

Care team reviews with patients and family pre-discharge to ensure clarity

Incorporating into pre-operative education to begin activating family earlier in care

Patient recovery guideavailable in the online Appendix

Clearly outlines post-discharge expectations (e.g., critical post-discharge appointments, team touch points)


Lesson 4

Optimize the Transitional Care Team

While an engaged patient is foundational to readmission avoidance, higher-risk patients require dedicated post-discharge support from knowledgeable caregivers. As such, it is critical to engage transitional care teams to support patients during this vulnerable time.

Many CV programs have already implemented transitional care teams (e.g., nurse navigators, care coordinators) for heart failure patients. However, this approach can be just as beneficial for procedural patients. A recent study found an NP-led transitional care program at one institution reduced 30-day CABG readmission rates from 11.5% to 4%.

Given this opportunity, it is necessary to evolve the transitional team approach to meet the needs of a broader patient population in a resource-efficient manner. Beyond expanding eligible conditions for transitional care to include procedural patients, CV programs must ensure they are deploying this intensive resource more strategically by targeting patients based on risk and leveraging staff to top of license.

Expanding an Effective Strategy to Procedures

Source: Hall MH, et al., “Cardiac Surgery Nurse Practitioner Home Visits Prevent CABG Readmissions,” The Annals of Thoracic Surgery, 97, no.5, (2014): 1488-1495; Cardiovascular Roundtable research and analysis. 1) North Shore-Long Island Jewish Hospital.

Dedicated Teams Provide Hands-On Support for Patient Transitions

Yesterday’s Model Today’s Need

Focused on initial discharge transition

Transition Care Effective for CABG Patients at NSLIJ1

30-Day CABG Readmission/Death Rate

11.5%

3.9%

Usual Care NP TransitionalCare Program

Evolving the CV Transition Team Model

Manage all patients with select conditions

Primarily target HF patients

Key Opportunities to Optimize Transitional Care Teams

Partner with hospital care management resources

Tailor supportbased on patient need

Ensure collaboration between CV, transition team

Standardize care pathway, education materials

Span entire continuum of care

Target patients based on risk

Manage all CV high-risk populations

Elements of the Transitional Care Program• Two NP home visits at 7-10 days

post-discharge

• Surgeon office visit at 10-14 days post-discharge

• Frequent NP follow-up calls

• 24/7 access to NP and on-call surgeon

• Smartphone to send pictures of incision to care team to review healing and ask questions

Study in Brief

• Researchers designed and tested a CABG transitional care program, leveraging cardiac surgery NPs to improve care continuity after discharge

• 169 CABG patients received intervention, 232 received usual care

• NP-led transitional care intervention led to a significantly lower 30-day readmission rate



When developing their own transitional care team for CABG patients, CV leaders at Nebraska Methodist were careful to complement Methodist’s existing care management initiatives, rather than duplicating efforts. Therefore, they have built a cohesive transitional care team strategy that leverages hospital-wide care management staff in addition to their own dedicated navigator.

The first element of this approach is Methodist’s “Health Services” team, which consists of tenured RNs who call complex patients after discharge to monitor their recovery. This is a hospital-wide program run out of the care management department, which they have now expanded to include CABG patients.

Second, Methodist has implemented a dedicated cardiac surgery transitional nurse navigator who provides CV-specific expertise. If the Health Services team identifies a patient requiring more targeted care, the cardiac surgery NP is able to provide more intensive care management. These two services are explored in greater depth across the next few pages.

Building a Cohesive Transitional Care Approach


1) CABG, CHF, AMI, outpatient surgery, pneumonia, colectomy, mastectomy, ED patients without primary care physician.

2) Nurse practitioner.

Care Management Team Calls Supplement CV Navigator Visits

Cardiac Surgery NP2 Navigator“Health Services” Team

Holds 72-hour post-discharge visit for each cardiac surgery

patient in follow-up clinic

Seven highly experienced RNs

Hospital-wide program run out of care management department

Hours: Mon-Fri: 7:30 a.m.–7:00 p.m. Sat-Sun: 8:30 a.m.–4:00 p.m.

Call complex patient populations1 post-discharge to monitor recovery

Available to see patients in clinic as needed for

urgent issues

Complementary Transition Services for CABG Patients

One NP with cardiac surgery background

Visits every cardiac surgery patient during acute stay to

begin transition planning



Nebraska Methodist’s Health Services team acts as the “first line of defense” post-discharge. This team of nurses calls CABG patients 24 hours after they leave the hospital, then again at one and three weeks post-discharge. They also act as the central point of contact to triage incoming questions from patients, which allows the CV NP navigator to work at top of license.

To better enable the Health Services team to monitor CABG patient recovery, the CV program provided Health Services the same cardiac surgery teach-back scripting their team uses to keep the information consistent across the continuum. If during the course of follow-up calls the nurses identify a patient who requires additional medical care, Health Services refers the patient to the cardiac surgery NP.

Health Services RNs the First Line of Defense


Follow-Up Calls Provide First Point of Contact, Ongoing Support

Calls to CABG Patients Use Standardized Teach-Back Scripting

RNs call designated cardiac surgery NP if patient requires additional medical care

Review medications

Ensure follow-up appointment scheduled

Inquire about wound care, healing

Check pain level

Ask if patient has questions, needs extra assistance

PatientPopulation

24 hours 1 week 3 weeks

CABG

CHF

AMI

Teach-back scripting and cardiac surgery NP job description available in the online Appendix

Health Services Script Health Services team uses same scripting CV team uses during inpatient stay

Intakes all patient questions, freeing NP navigator to seemore urgent cases



As complex CABG patients often need more specialized support than the Health Services team can provide alone, Methodist also implemented a cardiac surgery NP navigator. The NP sees each CABG patient in the outpatient clinic 72 hours after discharge, where she can identify complications, reduce patient anxieties, and reinforce the care plan. This bridges the gap before the physician follow-up visit with the CV surgeon, which is usually one to two weeks later.

The NP holds these appointments in the afternoon, but she is also on-call in the morning while rounding in the inpatient CV unit in case an emergent case is referred to her by the Health Services team. This prevents those patients from being readmitted unnecessarily through the ED.

Through the Health Services program and cardiac surgery NP navigator, Methodist has developed a cohesive, resource-efficient, transitional care strategy that ensures all CABG patients receive optimal, tailored follow-up management.

NP Navigator Bridging the Gap to Physician Visits


Accessible Post-Discharge Care for Cardiac Surgery Patients

72 hours

1-2 weeks

2-3 weeks

Multiple Touch Points Alongthe CABG Post-Discharge Pathway

• Urgent visits scheduled in morning

• Patients formerly admitted from ED for low-risk symptoms (e.g., chest pain) now managed by NP in clinic

Outpatient Clinic Schedule

Flex Hours

Standard Operating Hours

open slot

open slot

open slot

John Smith1 – 72 hr. follow-up

Mary Jones1 – 72 hr. follow-up

NP on CV floor at this time, but available as needed

Follow-up visitwith NP in clinic

PCP clinic appointment

Visit with cardiologist

CV surgery patient discharged

1-4pm

8am-12pm

Visit with CV surgeon

3-4weeks

NP Navigator Available forUrgent Cases in Outpatient Clinic



A second example of optimizing transitional care teams for procedural patients comes from Carolinas HealthCare.

Carolinas uses their CABG readmission risk assessment tool—discussed previously in Lesson 2—to determine what level of transitional care each patient needs. Carolinas enrolls very high-risk patients with multiple comorbidities in the Acute Illness Management (AIM) program. This is an intensive transitional care program consisting of a dedicated team and protocols, explored on the following pages.

While AIM is a hospital-wide care management program, CV leaders have incorporated it into their own transitional strategy for procedural patients.

A Specialized Team to Target Highest-Risk Patients

1) Two or more ED visits or hospitalizations in the last six months.2) Carolinas HealthCare System. 3) E.g., SNF, Hospice. 4) Active drug or alcohol abuser in the previous six months.


CV Collaborating with AIM Team for Most Complex Patients

AIM Team

Home health

“Heart Success”transition clinic

CV Patients Risk Stratified by Acuity toTailor Level of Post-Discharge Support

Acute Illness Management (AIM) Program

Incr

easi

ng P

atie

nt R

isk

Inclusion Criteria

• Actively managed in another care management program

• Lives in facility setting3

• Lives outside service area

• Active substance abuser4

• Unmanaged severe mental health disorder

• Multiple chronic conditions

• Polypharmacy

• High utilization pattern1

• CHS2 PCP or actively managing specialists

Exclusion Criteria



The multidisciplinary AIM team is well equipped to address chronic, complex patient needs. It consists of health coaches, social support services, and nurses who provide clinical guidance as needed.

The health coaches act as the primary points of contact for patients, visiting patients at home to perform med-rec, accompanying patients to follow-up visits, helping patients submit Medicaid or disabilities applications, and empowering patients to make healthy choices. The AIM nurses provide clinical guidance as needed.

To support the AIM team when working with CABG patients, CV leaders have developed guidelines and care pathways consistent with those used in CV settings across the continuum.

AIM Team Providing Intensive, Personalized Support

1) E.g., Medicaid, disability applications, advanced care planning. Source: Carolinas HealthCare System, Charlotte, NC; Cardiovascular Roundtable interviews and analysis.

AIM Health Coach Responsibilities

Reinforce patient education and discharge instructions

Work with patients on lifestyle choices (e.g., review food options)

Assist patients in findingcommunity resources1

Perform med-rec at patient’s home

Ensure follow-up visits scheduled; attend with patients as needed to ensure patient comprehension

AIM Team

• Five health coaches (LPNs)

• One NP

• One RN

• Two social workers

• Dietician, pharmacist, andbehavioral health as needed

Targeted Supportfor CV Patients

• CV and AIM leaders developed CV-specific pathways for AIM health coaches

• Ensure patients receive the same education and care as in CV clinic

Helping Patients Overcome Both Clinical and Psychosocial Barriers



The AIM care pathway is customized to meet the individual needs of each patient.

Upon referral to AIM, patients are risk stratified again to determine the level of support they require (e.g., frequency of outreach). Health coaches provide an initial home visit, followed by weekly phone calls for at least four weeks. If a patient requires additional medical care, the NP on the AIM team is able to visit them at home to provide a higher level of medical service.

Patients transition out of the AIM program either once they are able to self-manage between physician visits or once they are eligible for another less intensive program (e.g., home health).

Since inception, the AIM program has proven very successful in reducing the need for inpatient services. Across the first 18 months since the program launched in December 2013, the AIM team managed 190 patients and decreased inpatient utilization for these patients by 54%—a clear demonstration of the transition team’s effectiveness in managing highest-risk patients.

AIM Care Pathway Scaled to Meet Patient Needs


Tailored Support Reduces Need for Inpatient Services

Patients actively managed by AIM program in first 18 months

since the program started in December 2013

190Decrease in inpatient

utilization for AIM population since program inception

54%

AIM Program Pathway

Risk Stratification

Patients are riskstratified upon enrollment to determine frequency of contact

Patient Contact

Health coaches make one home visit and weekly phone calls for at least four weeks

Home Medical Care

AIM NP visits patients needing medical care at home

Transition

Remain with AIMuntil able to self-manage between physician visits with less intensive support (e.g., home health)



Given how valuable the AIM program is for complex patient transitions, CV leaders have started to build triggers into CV patient pathways—such as post-PCI—to hardwire AIM referral for appropriate patients. These pathways were developed for care settings across the continuum to ensure all members of the care team leverage this valuable resource as appropriate.

The Cardiovascular Roundtable provides a number of tools and resources to support developing and optimizing a high-risk transition team in the online Appendix.

AIM Program Built into Care Pathway for CV Patients

1) Acute coronary syndrome. Source: Carolinas HealthCare System, Charlotte, NC; Cardiovascular Roundtable interviews and analysis.

Trigger Hardwires Appropriate Referrals

ACS1/MI Patient Care Pathway

CV physician leader and AIM lead collaboratively developed care pathway

Home Health Options

Is Patient Homebound Does Patient

Have Chronic Medical Issues

Refer to AIM program

Telehealth Referral: ACS/MI Program

No

Yes

No

Yes

Ensures all members of care team (e.g., inpatient, ambulatory) refer appropriate CV patients to AIM

If Patient Does Not Quality

ACS/MI care pathways available in the online Appendix

• Non-PCI centers

• Office/ambulatory

• Hospital provider

• Nursing and case management


Lesson 5

Maximize High-Risk Transition Clinics for Procedural Patients

Procedural patients that do not require in-home, one-on-one support from a transition team often still require CV-specific care and monitoring in the immediate transition and post-discharge recovery period. Transitional clinics can provide this support and improve access to immediate care, reducing unnecessary ED visits, and have already been widely implemented for heart failure.

In fact, in 2011 approximately half of Cardiovascular Roundtable programs had a transition clinic for heart failure—a number that has likely risen over the years. However, the majority of programs do not operate a transition clinic for CV procedural patients, though the goals of transition clinics are just as relevant for this group.

Recognizing this, some programs have begun expanding their high-risk transition clinics beyond heart failure patients to include additional high-risk CV patient populations.

Taking Transition Clinics to a New Level

Source: 2011 Cardiovascular Roundtable Productivity Survey; Cardiovascular Roundtable research and analysis.

Expanding the High-Risk Clinic Model to Procedural Patients

Goals of HF Transition Clinics Just as Relevant for Procedural Patients

52%

Prevalence of Heart Failure Clinics

Percentage of Cardiovascular Roundtable Respondents, 2011

n=192

Memberswith

HF Clinic

Members Without

HF Clinic

Reduce unnecessary utilization and readmission

Increase patient satisfaction and activation

Improve care coordination and quality

Enable care team to work to top of license

Provide access to clinicians before follow-up physician appointment

Proactively identifysymptoms and complications



As an example is Carolinas HealthCare adapting its high-risk heart failure clinic to include procedural patients at risk of readmission.

As background, Carolinas’ transition clinic, called “Heart Success,” opened in 2011 at its flagship site, Carolinas Medical Center. The clinic’s purpose is to bridge the gap between discharge and physician management for the highest-risk heart failure patients.

Carolinas’ heart failure nurse navigator refers high-risk patients to the clinic prior to discharge, where they are managed through weekly visits for 30 days before returning to their PCP. The multidisciplinary clinic team includes three full-time physicians, HF specialists, dieticians, social workers, and pharmacists, addressing both the clinical and psychosocial factors that can lead to readmission.

Heart Success has proven to be extremely successful. Across the first three years, the heart failure readmission rate has dropped by six percentage points.

Given the success with heart failure, CV leaders saw an opportunity to expand the clinic to other patients who could benefit. Carolinas opted to stage its clinic expansion: first to CABG and valve, then to COPD and AMI, with the eventual goal to create a poly-chronic clinic that manages common chronic comorbidities under one roof.

Starting from a Solid Foundation

1) Clinic started in 2011, “after” results as of June 2015; same-facility readmissions from Carolinas Medical Center.

“Heart Success” Clinic Successfully Coordinating Care for High-Risk HF

• Bridges transition from acute to PCP care

• Began with high-risk HF patients

• HF nurse navigator identifies eligible patients in hospital and supports transition

• Patients meet with multidisciplinary clinic team weekly to manage clinical and psychosocial needs for one month post-discharge

Heart SuccessTransitional Care Clinic

Resulting in Decreased HF Readmissions Rate1

Initial Heart Success Clinic Team

HF patients who have used the Heart Success program

900

Seeing Great Success withHeart Failure Patients

• CV APP lead

• Three HF specialists

• Social worker

• Pharmacist

• RN

• Dietician

19.3%

11.7%

Before Clinic After Clinic




Heart Success leaders indicated that careful planning has been critical to an effective expansion, as it enabled them to pinpoint what infrastructure they could leverage from the existing model, versus making a new investment.

In fact, the majority of the infrastructure and resources in place for heart failure were sufficient for procedural patients, although there were a few necessary additions. With volumes projected to double, the clinic moved to a new space with six dedicated rooms and room to grow. Much of the diagnostic and lab equipment remains the same, although CABG patients require access to x-ray, labs, and infusion capabilities. Leaders are also developing cardiac surgery-specific protocols to ensure a consistent care plan for Heart Success patients. Interestingly, Carolinas only needed to add one FTE to accommodate the expansion. The Heart Success NP lead had the skills necessary to manage transitional care for procedural patients, so they only brought on a CV surgery RN to support the nuanced recovery needs of this patient group (e.g., monitoring wound healing).

Carolinas has proven that with careful planning, programs can adapt existing care coordination strategies to address procedural patient needs in a resource-efficient manner.

Expanding Transition Clinic to Cardiac Surgery

1) Number of visits dependent on patient acuity and education and resource needs.

Leveraging Existing Clinic Infrastructure to Support Procedural Patients

Benefits of Collocation

“Chronic CV patients have similar support needs—dieticians, social work, pharmacy—so it is in the best interest of the patients and the hospital to collocate staff and resources.”

Careful Planning for Efficient Expansion

• Six-month planning process

• Led by CV leadership, cardiac surgery NP, and Heart Success APP

• Determined resources needed to expand

Augmentations Necessary for Phase III

• Volume: Projected to double with expansion

• Space: New clinic contains 12 exam rooms with six designated for Heart Success, open Monday-Friday, 8 a.m.–5 p.m.; collocating with medical transitions clinic

• Staff: Same multidisciplinary team; adding one RN FTE to address surgery-specific care (e.g., wound care)

• Equipment: Onsite lab draw and infusion center

• Patient Identification: CV surgery APP identifies eligible high-risk patients during acute stay

• Visits: Maintain same weekly visit schedule: an average of three visits per patient1

• Care Plans: Developing surgery Heart Success plans, including consult triggers and when to refer back to PCP

Phase II Phase III Phase IVPhase I

HF Hospitalist High-Risk Transition Clinic

CABG, AVR, TAVR Additional Transitionsof Care Programs

2012 Q4 2015 Q1 2016 Q2 2016

Debbie Fenner Director, HF and Heart Success



Key Takeaways


Enable patients to self-manage after discharge by engaging patients and family in their care plan throughout the stay and improving education design and delivery.

Action Steps

• Start providing education as early as possible in patient care and reiterate throughout.

• Engage the family or caregivers in the patient’s care plan and education.

• Design patient-friendly post-discharge instructions that are easy for patients to understand and follow.

• Provide procedure-specific teach-back scripting to use across the continuum to reinforce instructions.

Optimize the transitional care team to provide targeted patient support tovulnerable patients, while ensuring efficient use of resources.

Action Steps

• Build a cohesive transitional care approach by leveraging resources from both the CV program and other care management programs across the hospital.

• Risk stratify procedural patients to identify the appropriate level of transitional support.

• Standardize CV procedural care pathways across transition teams to ensure consistency in referral points and patient management.

Maximize high-risk transition clinics for procedural patients to enable more intensive care management for the highest-risk patients.

Action Steps

• Evaluate developing a high-risk CV transition clinic if one does not currently exist at your program.

• If your program already has an HF transition clinic, determine what additional infrastructure would be necessary to expand to CV surgery and/or procedural patients (e.g., staff, exam space, training).

• Create procedure-specific referral tools and care pathways for the clinic.

Chapter 3 reviewed several imperatives for ensuring effective post-discharge transitions, including enabling

patients to self-manage, implementing transitional care teams, and maximizing transitional clinics for high-risk

procedural patients. Below are key action steps for CV programs to achieve this goal.


VV

V







Implementation Resources to Ensure Effective Post-Discharge Transitions


CV Surgery Teach-Back Follow-Up Call Scripting

NP Cardiac Surgery Navigator Job Description

CABG Patient Compact

Patient Post-Discharge Recovery Guide

Cardiac Survival Skills Patient Checklist

CV Surgery Patient Teach-Back

Bypass Surgery Patient Information

Health Services RN Job Description

Open Heart Surgery Patient Itinerary



Lesson 6: Ensure Appropriate Cardiac Rehab Utilization

Lesson 7: Coordinate with Providers Delivering Ongoing Care

Lesson 8: Prevent Unnecessary Admission from the ED


Chapter 4


CV programs can set patients up for success if they execute a smooth transition, leveraging strategies and tools such as those outlined in the previous chapter. However, programs must support these patients and their caregivers even once they are beyond the direct oversight of the hospital to ensure long-term success.

While procedural patients receive care in a variety of different locations after discharge, providers face similar challenges in caring for them regardless of location.

First, infections often do not manifest until seven to ten days after discharge, and non-CV caregivers might not be equipped to proactively identify and manage these infections.Second, many patients have to travel outside their communities to receive CV procedures at tertiary hospitals. After discharge, they return to their local physicians who are less familiar with the care they received. As evidence of the challenge this poses, 50% of CABG readmissions are to hospitals other than where the surgery was performed.

The remainder of this publication will address strategies for helping key partners in post-procedure care optimize longitudinal care management.

New Hurdles in Post-Discharge Care Management

Source: Shahian DM, et al., “Development of a Clinical Registry-Based 30-Day Readmission Measure for Coronary Artery Bypass Graft Surgery,” Circulation, 130, (2014): 399-409; Cardiovascular Roundtable research and analysis.

CV Procedural Patients Present Unique Challenges from Medical Patients

Community Providers Without CV Background

Infections Manifesting After Discharge

• Delayed occurrence of procedural complications

• Post-discharge providersmust be able to identifyinfections early

• Patients more likely to travel for procedures than medical care; return to community physician for follow-up care

• Local providers less familiar with complex CV patients and default to ED if issues arise

CardiacRehab

HomeHealth

SNF Emergency Department

Nuances to Address in Post-Discharge Procedural Patient Management

1 2

Percentage of CABG readmissions to hospitals other

than where surgery was performed

50%Length of time after discharge common infections appear

7-10 days

CABGPatient


Lesson 6

Ensure Appropriate Cardiac Rehab Utilization

One of the immediate opportunities for programs to optimize post-discharge care is ensuring appropriate cardiac rehab utilization.

Hospitals have been using outpatient cardiac rehab to optimize patient recovery for years. However, it is receiving increased attention recently with the greater focus on readmissions, both medical and procedural.

As one expert explained, one of the most important benefits of cardiac rehab is that a clinician familiar with CABG recovery is seeing the patient frequently enough to catch complications. As evidence, a recent study found CABG patients that don’t attend cardiac rehab are three times more likely to be readmitted than those who do attend.

Cardiac Rehab Back in the Spotlight

Source: Pack QR, et al., “Participation in Cardiac Rehabilitation and Survival After CABG Surgery,” Circulation, 128, (2013):590-597; Clark AM, et al., “Meta-Analysis: Secondary Prevention Programs for Patients with Coronary Artery Disease,” Annals of Internal Medicine, 143, (2005): 696-672; Hedbäck B, et al., “Cardiac Rehabilitation After Coronary Artery Bypass Surgery,” Journal of Cardiovascular Risk, 8, (2001): 153-158; Cardiovascular Roundtable interviews and analysis.

Renewed Focus in Light of Procedural Readmission Penalties

10-year relative risk reduction in all-cause mortality due to participation in cardiac rehab following CABG

Reduction of recurrent MI at 12 months when CABG patients attend rehab

Increased likelihood of readmission for CABG patients who do not attend cardiac rehab compared to those who do attend

Improved Outcomes When CABG Patients Attend Rehab

46%

17%

Experts See Benefit in Cardiac Rehab

“Beyond the clinical services patients receive, the key benefit of outpatient rehab is it makes certain that somebody knowledgeable is seeing the patient regularly—someone who knows the typical course of a patient’s recovery after CABG who can quickly address any concerns.”

3x

Cardiac Surgeon, VP of Quality and Safety Academic

Medical Center in the Northeast

Access the Cardiovascular Roundtable webconference Cardiac Rehabilitation Services Excellence for key strategiesfor successful program implementation


While the benefits of cardiac rehab are clear, it is still a vastly underutilized resource. Just over half of eligible MI, PCI, and CABG patients are referred to cardiac rehab and out of that only 19% enroll.

There are a number of factors that could be causing this underutilization. For instance, physicians may not be familiar with the appropriate method to identify or refer eligible patients due to lack of referral standardization. Similarly, patients might not be educated on the full benefits of cardiac rehab, and may have difficulty paying copays. Additionally, reimbursement for cardiac rehab is not favorable, further deterring institutions from emphasizing rehab.

However, despite these challenges, there is now a considerable return on investment that can be attributed to programs in terms of readmission penalty avoidance. Given this additional incentive, there is now an opportunity for institutions and providers to place greater emphasis on ensuring cardiac rehab referral and attendance for procedural patients.

In addition to the examples outlined on the following pages, experts in the field have offered several other strategies to increase referral and enrollment in cardiac rehab, outlined in the accompanying table.

Time to Double Down in Light of Underutilization

Source: Brown TM, et al., “Predictors of Cardiac Rehabilitation Referral in Coronary Artery Disease Patients,” Journal of the American College of Cardiology, 4, no. 6 (2009): 515-521; : Balady GJ, et al., “Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond: A Presidential Advisory from the American Heart Association,” Circulation, 124, (2011): 2951-2960; Wright S, “Increasing Cardiac Rehab Participation,” AACVPR; Cardiovascular Roundtable research and analysis.

Low Referral Rates, Loss to Follow-Up After CV Procedures

Vast Underuse of Cardiac Rehab

Percentage of eligible patients referred to cardiac rehab following MI, PCI, or CABG56%

Primary Reasons

Percentage of Medicare patients enrolled in cardiac rehab following MI or CABG

19%

Key Opportunities to Leverage Cardiac Rehab as a Readmission Reduction Tool

Hardwire referral for eligible patients

Monitor referral, patient attendance by physician

Educate patients on the value of rehab during stay

Encourage attendance in follow-up calls

• Lack of standard referral method

• Patients not aware of the value of attendance; difficulty paying copay

• Lack of familiarity with cardiac rehab among referring physicians

• Reimbursement not always favorable

Literature Provides Additional Strategies to Improve Cardiac Rehab Referral and Enrollment

Methods to Facilitate Referral and Enrollment in Cardiac Rehab

Include referral to cardiac rehab in hospital discharge plan

Make comprehensive interpreter service available if required

Automatically refer all eligible patients at the time of hospital discharge

Provide transportation and parking assistance if required

Have office staff ensure that referrals are completed

Follow-up with those referred but not enrolled

Provide patients with a choice of cardiac rehab to attend

Improve insurers understanding of cardiac rehab

Ensure patients are aware of and agree to the referral

Flex hours based on patient’s needs

Arrange personal visits from cardiac rehab liaison

Partner with other local hospital cardiac rehab program

Provide written invitations and program brochures in multiple languages

Build cardiac rehab into patient compact



CV leaders at Nebraska Methodist recognized the importance of cardiac rehab, but were concerned over low utilization. They identified two fundamental barriers driving this.

First, physicians were not referring appropriate patients to cardiac rehab. To address this challenge, the hospital standardized order sets to ensure referral to rehab is now the default option for eligible surgical and procedural patients.

The second challenge CV leaders identified was patient noncompliance: even if referred, patients were not enrolling. In response, Nebraska Methodist streamlined enrollment by completing all rehab paperwork and pre-certification while the patient was still in the hospital. Additionally, the CV program built cardiac rehab into the follow-up call scripting their Health Services team uses to further encourage attendance.

Getting Patients to Their First AppointmentDual Strategies to Encourage Cardiac Rehab Enrollment

Physicians not referring patients to cardiac rehab

Automate Referrals

Referred patients do not make first appointment

Challenge Identified Strategy to Address

Engage Patients Early

• All paperwork and pre-certification completed in hospital before discharge

• Ensure patients begin program within three days

• Health Services RNs call patients to monitor progress and identify patients not attending

• Hospital standardized order sets to automate referrals following cardiac surgery, CV procedures

• Providers must manually uncheck box on order set if they do not want patients referred for rehab




Carolinas HealthCare is also dedicated to ensuring their CV patients receive cardiac rehab. It is no surprise why, as the readmission rate from cardiac rehab at Carolinas Medical Center is at just 2%.

To encourage broader utilization of this valuable service, Carolinas diligently tracks rehab referrals and attendance. CV leaders assess this data monthly to pinpoint opportunities for improvement and encourage physician engagement in their efforts. Moving forward, the CV program aims to collect data on Carolinas patient attendance at rehab programs across the state—not just those run by Carolinas—to get an even more comprehensive picture.

Both Nebraska Methodist and Carolinas have found that hardwiring referrals and enrollment can successfully drive rehab attendance for patients who can benefit from this post-discharge care.

Encouraging Ongoing Rehab Attendance

1) Carolinas Medical Center main campus.

CV Leaders Assess Data Monthly to Improve Referral, Attendance Rates


Track Data Across Sites

Monitor Attendance

Instituted automatic referral process for all CV procedural patients

Rehab data collected monthly, assessed by CV leaders

• Time from referral to orientation

• Time from orientation to start

• Referral to start percentage

• Percentage of patients readmitted who are part of rehab program

Collect data on patient attendance from programs across state

Automate Referrals

Current Strategies Future Strategies

2%Readmission rate from cardiac rehab

CV leaders use data to:

• Connect with physicians not referring appropriately

• Educate CV physicians about process and need for cardiac rehab

• Focus on readmission efforts

• Identify opportunities to decrease time to rehab orientation and start


Lesson 7

Coordinate with Providers Delivering Ongoing Care

Cardiac rehab is a valuable resource, but it’s just one piece of the post-discharge care pathway. Patients go to a range of post-acute locations after discharge. In fact, the majority of readmitted CABG patients are discharged to home health, home, or skilled nursing facilities (SNFs).

Unfortunately, community providers—whether in post-acute care facilities or physician offices—may not be fully equipped to manage complex CV procedural patients.

There are several key opportunities for CV programs to support these providers in delivering high-value care to post-discharge CV patients: offer CV-specific training to better enable providers to manage procedural patients; ensure patients are triaged to the appropriate level of post-discharge care; enable providers to contact the patient’s CV provider for additional support when necessary; and build cross continuum care pathways to ensure patients receive the appropriate care at each stage in the continuum.

Long-Term CV Care Management Not an Easy Feat

Source: Crimson Continuum of Care, Cardiovascular Roundtable research and analysis.

1) Following index admission.2) Crimson Continuum of Care, n=114 hospitals, 2013-2014.

Community Providers Require Additional Support for Procedural Patients

Initial Discharge Destination of CABG Patients Readmitted Within 30 Days1

38%

29%

22%

7%4%

Inpatient Rehab

HomeHealth

SNF

Percentage of Readmitted CABG Patients2

Home

Other

Challenges for Providers

Frequently not located near index admission hospital

Unclear when necessary to referpatients back to surgical team

Limited communication withoriginal surgical care team

Lack of CV care pathways

Key Opportunities to Coordinate with Providers Delivering Ongoing Care

Provide CV-specific training for caregivers

Triage to appropriate level of post-discharge care

Ensure ability to contact CV provider for support

Build cross-continuum care pathways



New Hanover Regional Medical Center recognized the importance of providing CV specific guidance for post-discharge care management services. As such, they have been able to leverage two hospital-wide services to address the CABG patient population: home health RNs and community paramedics. The details of these two programs are explored on the following pages.

Triaging Home Care Support by CABG Patient Risk


Cohesive Strategy Provides Right Level of Support Post-Discharge

• CABG patients enrolled in NHRMC home health get at least one visit from nurse

• Uninsured patient visits covered by case management department

• Employed by medical center; salary comes from case management budget

• Identified a cohort of CV-specific home health nurses, led by former CV ICU nurse

CV Home Health RNsProvide home care management servicesfor high-risk patients

Community ParamedicsProvide home visits for highest-risk patients, frequent ED utilizers

Details of Program

• Inpatient case managers identify highest-risk CABG patients and refer to community paramedics while patients still in hospital

• Employed by medical center

• Tenured paramedics in previous leadership roles selected for role

• Program started with 2.5 FTEs and recently expanded to 4.5 FTEs

Details of Program



When assessing their longitudinal care coordination strategy for CABG patients, CV leaders felt these patients would benefit greatly from home health visits, but recognized they would require more CV expertise.

Therefore, they developed a cardiac surgery-specific training program for a select group of their employed home health nurses. The training includes education on managing post-op recovery as well as the opportunity to shadow cardiac surgeons for procedures and office visits. This helps build both experience and a rapport with the surgeons.

New Hanover also developed CABG home health protocols to guide the nurses during visits. The protocols outline what vitals and symptoms to watch for, how to proactively identify infections, and when to contact a physician. Nurses visit each CABG patient at least once, and up to three times based on their acuity.

Engaging home health nurses is ideal for managing psycho-social concerns, patient questions, and identifying complications. However, some patients require more clinical support in the home to avoid a trip to the ED. For these patients, New Hanover's community paramedicine program is a more appropriate option, as described on the next page.

CV-Trained Home Health Nurses

1) If patient chooses to enroll in NHRMC home health program.Source: New Hanover Regional Medical Center, Wilmington, NC; Cardiovascular Roundtable interviews and analysis.

Equipping Post-Acute Caregivers to Manage CV Surgery Patients

CV Home Health Nurse Program

Visit each CABG patient1 one to three times based on acuity

Home health nurse job description and CV surgery post-operative protocol available in the online Appendix

Follow standard protocols and checklist created by CV surgeons

Shadow cardiac surgeons during patient visits to gain CV surgery expertise and develop trust and rapport

Cardiovascular Surgery Post-Operative Protocols

Vital Signs

Referrals

Community Paramedics (make MD office aware)

Activities

If home health nurses identify patient with ongoing problem, can request community paramedic involvement to monitor patient for longer period of time

• Assess apical pulse, daily weights, temperature and blood pressure record on vital sign record

• Report any changes in regularity of heart rhythm• Use Telemonitor for all patients if available and

appropriate for patient

• May order nursing, home health aide, social work, or rehab as needed

• May decrease visits when applicable

• Call for EKG if irregular arrhythmia noted and patient not symptomatic



In 2013, leaders from the local EMS department and New Hanover identified significant overutilization of 911 and the ED for non-emergent issues that could be managed in a patient’s home. In response, they developed a program through which community paramedics would be deployed to the homes of ED “frequent fliers” whenever they called 911 to address their low-acuity concerns in-house rather than bringing them to the ED. These paramedics are able to provide a higher-level of clinical support than home health nurses are allowed through their scope of practice.

New Hanover began with a six-month pilot with two experienced paramedics following two chronic patients. Rather than sending an EMS team to take a patient to the ED, the community paramedics would go to the patients when they called. As a result of the pilot’s success, the program expanded to include all heart failure and frequent ED patients. The community paramedicine program now has four, full-time, tenured community paramedics.

Since expansion, the program has demonstrated broad success, including a 10 percentage point drop in 30-day heart failure readmission. Given the program’s success with heart failure, in February 2015 the program expanded once again, this time to include CABG patients.

Community Paramedics Visit Highest-Risk Patients


Diverting ED Utilization Through Home Management When Possible

Initial Pilot Targets HF

Program Expansion

• Identified subset of patients frequently presenting to the ED with low-acuity concerns

• Developed community paramedics program to manage patients at home when possible, avoiding an ED visit

• Six-month pilot included two paramedics, one HF patient, and one frequent ED user

• Patients instructed to call paramedics rather than 911 for non-emergent needs

• Program success led to grant support to expand program

• Hired two additional paramedics

• Expanded initially to all HF and frequent ED patients

• 30-day HF readmission rate dropped to 9%

• Due to program success, expanded to CABG in early 2015

Overview of Community Paramedics Program Rollout

Opportunity to Manage Unnecessary ED Use



As with the home health program, New Hanover developed a CV surgery-specific training module for community paramedics upon opening the program up to CABG patients. Paramedics shadow a CV surgeon during a CABG procedure and patient follow-up visits in the CV clinic. In all, paramedics complete 24 CV surgery training hours, through which they learn the typical course of a CABG patient’s recovery, what symptoms are abnormal, and how to identify wound infections.

In addition to training, there is an established care pathway for CABG patients in the community paramedics program. Very high-risk CABG patients are referred to the community paramedics program before discharge so paramedics visit the patient while still in the hospital to explain the program and begin developing trust. Paramedics then conduct a comprehensive initial home visit with the patient to evaluate their living situation, identify any barriers to recovery, review medications, and begin coaching them on health skills, like diet improvement.

From that point onward, if the patient has an urgent need, the community paramedics program will respond versus general EMS, managing them in-home where possible, or taking them to an appropriate care setting.

Program a Valuable Resource for CV Patients


CV Surgery Training Enables Paramedics to Provide Home Care

CV Surgery Training for Community Paramedics

• Shadow CV surgeon to view CABG procedure

• Round with surgeon during patient follow-up appointments

• 24 hours of specific training

Key Benefits

Paramedics learn the courseof CABG recovery, including:

• How a patient’s chest should feel

• How patients should feel at week one and week two

• Risk factors indicative of need for further treatment (e.g., infection)

Paramedics develop trust and rapport with CV surgeons

Community Paramedic Management of CABG Patients

1

2

Instruct enrolled patients to call CV paramedics instead of 911 when needed

Case managers identify high-risk patients and refer them to community paramedics

Paramedics meet patients during acute stay to explain program and establish trust

• Evaluate patient diet

• Provide nutrition education

• Perform med-rec and medication management assistance

• Assess patient wounds to ensure proper healing and recovery

• Make shared decision plan including goals and action steps with patient

Provide initial home visit to:



Overall, the community paramedicine program has been successful for all parties. The program has reduced EMS utilization, unnecessary ED visits, and readmissions to the medical center. Patient satisfaction scores of 92% also demonstrate how patients value the personalized support. As the program just expanded to CABG patients, CABG-specific readmissions results were not available at the time of publishing, but New Hanover leaders are confident that the program is just as beneficial for this population.

Community paramedicine is not unique to New Hanover’s market, with programs developing across the country. CV leaders have an opportunity to step in early to build relationships and support paramedics as New Hanover did to avoid unnecessary readmissions for complex CV patients.

Approach Yielding Benefits Across the Board

1) Patients rated program a 4.6 on a scale to 5. 2) As of Q1 2015.


Community Paramedics Program Improves Patient Care, Satisfaction

• Reduces ED utilization

• Increases appropriate resource utilization

• Elevates patient, surgeon and staff satisfaction

EMS Program

92%

Readmission rate of all patients in community paramedics program2

• Reduces EMS utilization

• Provides professional development opportunitiesfor seasoned EMTs

Employed EMS Program Not Critical for Success

While NHRMC has employed paramedics, the program can be equally effective without employment as long as both parties design mutual agreement on provisions (e.g., education, equipment)

Medical Center

A Mutually Beneficial Arrangement

9.1%

Yielding Positive Results on Patient Care

Patient satisfaction with community paramedic program1

Will monitor impact on CABG readmissions going forward



While many procedural patients will receive some post-discharge care through cardiac rehab or a post-acute provider, nearly all patients will return to PCP management at some point. Therefore, it is critical to have adequate support from the CV program to care for these patients.

The CV team at Carolinas has developed cross-continuum care pathways to outline how community providers can care for their patients longitudinally. These pathways ensure consistent, evidence-based practice, regardless of where a patient is receiving care.

Currently they have developed pathways for ACS patients for the inpatient setting, PCI and non-PCI centers, and ambulatory management.

Supporting Physicians in Long-Term CV Care


ACS Pathway Reduces Care Variation Across Continuum, Caregivers

Cross-Continuum Pathway Development

Bridge transitions to outpatient clinic and ongoing ambulatory management

Set up as “playbook” to ease provider understanding and encourage utilization

Support all providers caring for AMI and ACS patients in the hospital and for cardiologists and PCPs in the ambulatory setting

Goals of Pathway

Recognized opportunity to reduce care variation for MI and interventional patients seen by various clinicians

1

Multidisciplinary team created standardized ACS care pathway

2

Piloted with two CV providers in early 2015 and refined as needed

4

• Data analytics team

• Staff nurse

• Medical Director, CV Interventional Services

3 Four versions developed:


• Office-ambulatory management

• Director of H&V Institute

• PA

• NP

• Quality team

• Non-PCI centers

• Nursing and case management



Carolinas’ cross-continuum pathways identify where a patient should receive care based on risk and what should take place at each stage. This delineates roles between caregivers, helps community physicians care for CV patients, and provides triggers for when they should consult with the treating specialist.

Carolinas just began piloting these care pathways in early 2015, but anecdotally CV physician leaders feel the tools increased community physician comfort in providing appropriate, evidence-based care for post-procedure patients. They plan to incorporate the pathways into the EMR, and are also considering developing protocols for other procedures.

CV programs must support non-CV providers who are management CV procedural patients’ long-term care—such as through CV training and protocols—to ensure optimal outcomes and reduce unnecessary readmissions.

Longitudinal Pathways Ensure Consistency, Quality


Guiding Evidence-Based Care Delivery Across the Continuum

ACS Care Pathway

Confirms patients are attending cardiac rehab

Ensures patients are following appropriate medication regimen

Documents readmission risk for care transition planning

Triggers AIM program referralfor highest-risk patients

Please access the online Appendix for the following ACS/AMI pathways:


• PCI centers: nursing and case management

• Non-PCI centers

• Office-ambulatorymanagement

Plans to incorporate pathway into EMR


Lesson 8

Prevent Unnecessary Admission from the ED

The final step in optimizing longitudinal care management for CV procedural patients is preventing unnecessary admission from the ED. Each of the previous strategies focus on how to prevent procedural patients from returning to the hospital. However, despite best efforts there will always be some cases where procedural patients end up back in the ED. One study shows 18% of PCI patients and 24% of CABG patients return to the ED within 30 days of discharge. Further complicating the matter, patients are readmitted for several comorbidities that may disguise the initial diagnosis.

Unfortunately, the default when a patient with CV symptoms presents to the ED is to admit. However, often these patients can be effectively managed in observation or an outpatient clinic. Therefore, it is essential for the CV program to support ED clinicians in promptly triaging CV patients to the appropriate level of care.

Clear Opportunity to Reduce Admissions from the ED

Source: Crimson Continuum of Care; Kocher KE, et al., “ED Visits After Surgery Are Common for Medicare Patients, Suggesting Opportunities to Improve,” Health Affairs, 32, no. 9, (2013): 1600-1607; Fox JP, et al., “Hospital-Based, Acute Care Use Among Patients Within 30-days of Discharge After CABG,” Annals of Thoracic Surgery, 96, no. 1 (2013): 96-104; Cardiovascular Roundtable research and analysis.

1) Medicare patients. 2) Crimson Continuum of Care, n=114 hospitals, 2013-2014.

High ED Utilization for CV Procedural Patients

Rate of ED visits within 30 days post-PCI118%

Rate of ED visits within 30 days post-CABG124%

Key Opportunities to Prevent Unnecessary Admission from the ED

Provide ED clinicianeducation

Implement alerts for potential readmissions

Develop diagnosis-specific protocolsfor ED

Expand chest pain unit to accommodatemore CV diagnoses

Comorbidities May Disguise Index Procedure

Top DRGs Driving CABG 30-Day Readmissions2

MS-DRG Description

1 292 HF & shock w/ CC

2 291 HF & shock w/ MCC

3 863Post-op & post-traumatic infections w/o MCC

4 871Septicemia or severe sepsis w/o Mv 96+ hours w/ MCC

5 309Cardiac arrhythmia & conduction disorders w/ CC



One strategy to ensure appropriate triage of returning procedural patients is to assign the triage responsibility to a designated provider in the ED.

In 2014, Nebraska Methodist implemented an ED case manager to triage presenting patients. While not CV-specific, the case manager knows to contact the cardiac surgery NP navigator when a CABG or valve patient presents to the ED to determine if they truly require an inpatient admission.

After a few months with this role in place, ED staff have become better equipped to redirect these patients to the cardiac surgery NP for further guidance, even when the case manager is not present.

ED Case Manager Triages Returning Patients


Supports ED Physicians to Bypass Unnecessary Readmissions

ED Case Manager Restructured Care Pathway for Returning CV Procedural Patients

Contact NP for CV Patients

If CABG/valve patient returns to ED, case manager contacts cardiac surgery NP before admitting

Disseminate Knowledge

ED staff learn to redirect patients to cardiac surgery NP, even if case manager is not present

Background:

• Hospital created ED case manager role in December 2014 to identify andtriage patients returning to ED

• Former ED nurse brought on to garner ED physician trust and support of role

Goals:

• To avoid unnecessary admission (e.g., discharge patients with home health follow-up), expedite referrals if inpatient admission needed

Details:

• Hours: M-F, 9 a.m.–5:30 p.m.

• Salary from Care Management budget

Job description available in the online Appendix



In a second example, New Hanover has developed several complementary strategies for reducing unnecessary admissions from the ED.

First, understanding that the majority of procedural readmissions are due to common comorbidities—like AFib and heart failure—CV leaders expanded their successful chest pain center to a broader CV observation unit that captures the majority of returning post-procedure patients. The goal of the unit is to promptly assess the risk level of these patients and determine if they should be admitted or discharged for outpatient follow-up.

The unit is open 24/7 with nine beds, although they are able to flex census into the adjacent inpatient unit if necessary. To facilitate rollout and encourage appropriate use of the expanded unit, the unit's Medical Director (who is also a cardiologist) provided education in departmental meetings and training modules across the six weeks before expansion.

Chest Pain Center Expanded to CV Observation Unit

Source: New Hanover Regional Medical Center, Wilmington, NC; Cardiovascular Roundtable interviews and analysis. 1) Nursing assistant.

Unit Now Encompasses Key Conditions Driving Procedural Readmission

Targeting Unnecessary Readmissions from the ED

• Expanded to include AFib, HF, and syncope patients

• Same staffing model

• Maintained nine beds, with ability to flex census into adjacent inpatient unit while keeping observation status

• Communication of expansion took place across six weeks prior to rollout through department meetings and education modules

• AFib and HF are top drivers of procedural readmission

• Post-procedure patients often return to ED with anxiety and low-risk symptoms that can be managed outpatient

• Patients often admitted due to lack of ED protocols for identifying and discharging low-risk patients

• Nine beds, adjacent to ED

• Open 24/7

• Goal to promptly assess risk of chest pain patients presenting to ED and triage to appropriate care setting

• Managed by a cardiologistMedical Director

• Hospitalists cover unit while cardiologists provide consults

• Staffed with two RNs and one NA1

per shift

X

Expanding Unit to Accommodate Key Conditions

CV Observation UnitED Chest Pain Unit



To ensure appropriate utilization of the expanded observation unit, New Hanover developed short-stay protocols for common CV comorbidities leading to post-procedure readmission: heart failure, AFib, syncope, and chest pain.

These protocols help ED physicians and observation unit staff identify and triage ED patients to the appropriate care setting. The CV medical director and observation unit leaders educated ED physicians on the new protocols, and attached the protocols to medical records during rollout to ensure utilization.

New Short-Stay Protocols Support UnitEncouraging Appropriate Utilization of Expanded Observation Unit

• Cardiologist team developed short-stay protocols for HF, AFib, syncope, and chest pain over three months

• Aim to support ED physicians and CV observation unit staff in identifying and triaging patients to appropriate care setting

• CV Medical Director and observation unit leaders provide training sessions

• Attached protocols to medical records

• Collaborate with case management in ED to keep short-stay protocols top of mind

• Protocols embedded into EMR to be used whenever eligible patients present

• Low-risk patients triaged to observation unit rather than admitted to inpatient unit

Protocol Development1

ED Physician Education2

Implementation3

HF

AFib Chest pain

Syncope

CV Short-Stay Protocols

Protocols available in the online Appendix




Even with protocols in place, the presence of comorbidities may disguise that a returning patient had previously been in the hospital for a CV procedure. Therefore, New Hanover has put a final, simple, safeguard in place to ensure their ED strategies are used: an EMR alert for readmitted patients.

When a patient comes to the ED within 30 days of a previous admission, an “active flag” appears in their record to clearly alert the ED physician. This reinforces use of the short-stay protocols and the observation unit, if appropriate. For instance, if a patient returns post-CABG, the ED physician is alerted to consult with the performing surgeon for guidance on next steps.

While CV procedural patients will ideally not return to the hospital, there are some circumstances where they will present to the ED after discharge. In such situations, it is critical to ensure they are managed promptly, and treated in the most appropriate setting.

Proactively Identifying Avoidable Readmissions in the ED

Source: New Hanover Regional Medical Center, Wilmington, NC; Cardiovascular Roundtable interviews and analysis. 1) Applies to all patient populations, not diagnosis-specific.

EMR Alert Ensures Returning Patients Triaged Appropriately

Flag alert appears in EMR if patient was dischargedwithin past 30 days1

Patient presentsto ED

Triage to CV Observation Unit

If post-CABG patient, ED physicians call for CV surgeon consult; not to admit patients without surgeon’s approval

Call CV Surgeon

If not post-CABG, continue to follow CV short-stay protocolsand send patient to observation unit

Triggers CV short-stay protocols if patienthas symptoms of:

• HF

• AFib

• Syncope

• Chest pain


Key Takeaways


Ensure appropriate cardiac rehab utilization by engaging and educatingpatients and providers of the value of this service.

Action Steps

• Build referral to outpatient cardiac rehab into post-procedure discharge order sets as a default.

• Streamline attendance for patients by completing paperwork and pre-certification before discharge.

• Provide follow-up calls to encourage attendance.

• Monitor referrals and utilization of rehab to ensure providers are using the resource appropriately.

Coordinate with providers delivering ongoing care to optimize patient recovery and ensure early identification of post-procedure complications.

Action Steps

• Risk stratify patients to ensure appropriate level of post-discharge care support.

• Provide CV procedure-specific education to providers who will be managing these patients post-discharge (e.g., home health, post-acute care facilities, community paramedics).

• Create standardized care pathways to reduce variation in care settings across the continuum.

Prevent unnecessary admission from the ED through patient triage to appropriate care setting.

Action Steps

• Build triggers into the EMR to identify returning patients and secure specialist consults before admitting.

• Ensure ED caregivers are aware of optimal diagnostic pathway for returning procedural patients.

• Expand existing chest pain observation units to better accommodate CV procedural patients.

• Implement ED short-stay protocols for common CV diagnoses leading to readmissions.

Chapter 4 reviewed several imperatives for optimizing longitudinal care management, including ensuring

appropriate cardiac rehab utilization, coordinating with providers delivering ongoing care, and prevent unnecessary

admission from the ED. Below are key action steps for CV programs to achieve this goal.


VV

V







Implementation Resources to Optimize Longitudinal Care Management


Observation Unit Protocols for CV Patients

Home Health Nurse Job Description

Home Care Management of the Heart Surgery Patient

ED Case Manager Job Description

Cardiac Surgery Care Pathway

ACS/AMI Care Pathways:

• Hospital Provider

• Nursing and Case Management

• Non-PCI Center

• Office-Ambulatory Management



Expand the Ambition for Longitudinal CV Care

Coda


Together, the eight lessons reviewed in this publication will help programs build a comprehensive approach to reducing CV procedural readmissions.

While these efforts may seem like a vast undertaking, as discussed in the introduction, the majority of these strategies will reduce readmissions for a range of CV conditions beyond CABG, whether bolstering existing heart failure efforts or preparing for conditions that are likely to face future scrutiny.

Strategies Bolstering Broader Readmission EffortsLessons Apply to Both Medical and Procedural Patients

Lesson for Reducing Readmission

Surgical (e.g., CABG, valve)

Interventional (e.g., PCI, PV)

Medical(e.g., HF)

1 Reduce Risk of Post-Procedure Complications

2 Coordinate Care AcrossPatient Recovery

3 Enable Patients toSelf-Manage

4 Optimize the TransitionalCare Team

5Maximize High-Risk Transition Clinics for Procedural Patients

6 Ensure Appropriate Cardiac Rehab Utilization

7 Coordinate with Providers Delivering Ongoing Care

8 Prevent Unnecessary Admission from the ED

Applicable CV Patient Populations



These efforts will be pivotal not only for success against current 30-day readmissions metrics, but also to prepare for a new era of utilization scrutiny. The HRRP metrics just scratch the surface when compared to other policies on the horizon, from the AMI and HF “Excess Days” measures, to 90-day bundled payments, and true population health models. These metrics will come with their own new challenges, but to succeed, programs must begin establishing a foundation for cross-continuum quality now.

By reducing unnecessary CV readmissions today, programs are building the infrastructure that will prepare them for the new pressures of a value-based world.

Readmissions Just the Tip of the IcebergLaying the Foundation to Prepare for Future Cross-Continuum Mandates

• AMI, HF, “Excess Days” measures

• 60-, 90-day bundles

• Admissions after outpatient procedures (e.g., PCI, vascular)

• Capitated/accountablecare models

• “Healthy days at home” metric proposed by MedPAC

• Outpatient utilization scrutiny

BroaderUtilization Scrutiny

Total Population Management

30-Day Readmissions

• Hospital Readmissions Reduction Program

Today’s Focus Potential Future Pressures

Future Policies, Metrics Intensifying the Focus on Longitudinal Care




Appendix



Implementation Resources Available in the Online Appendix


• Cardiac Surgery Quality Dashboard, New Hanover Regional Medical Center

• CABG Bundled Payment Dashboard, Maine Heart Center

• PCI Bundled Payment Dashboard: Sparks Health (pseudonym)

• STS Quality Performance Measure for CABG

• CV Appropriate Use Resource Compendium

• Risk Stratification Tool Compendium for CV Procedural Readmission

• Complication Risk Mitigation Pathways for Cardiac Surgery Patients, Carolinas HealthCare

– Renal Failure

– Pulmonary Complications

– Stroke

• Extubation Fast-Track Criteria, Sharp HealthCare

• CT Surgery Readmission Risk Assessment, Carolinas HealthCare

• CV Bedside Handoff Report, Nebraska Methodist Hospital

• Open Heart Surgery Patient Itinerary, Elmhurst Memorial Healthcare

• CV Surgery Teach-Back Scripting, Nebraska Methodist Hospital

• CABG Patient Compact, Geisinger Health System

• Bypass Surgery Patient Information, Cleveland Clinic

• Heart & Lung Surgery Patient Recovery Guide, Carolinas HealthCare

• NP Cardiac Surgery Navigator Job Description, Nebraska Methodist Hospital

• CV Surgery Teach-Back Follow-Up Call Scripting, Nebraska Methodist Hospital

• Health Services RN Job Description, Nebraska Methodist Hospital

• ACS/MI Care Pathways, Carolinas HealthCare

– Hospital Provider Based

– Nursing and Case Management

– Non-PCI Center

– Office and Ambulatory Management

• Home Care Management of the Heart Surgery Patient, New Hanover Regional Medical Center

• Home Health Nurse Job Description, New Hanover Regional Medical Center

• Cardiac Surgery Care Pathway, Nebraska Methodist Hospital

• ED Case Manager Job Description, Nebraska Methodist Hospital

• Observation Unit Protocols, New Hanover Regional Medical Center

Access these resources and more online at: advisory.com/cr/proceduralreadmissionstoolkit


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