UCSF Medical CenterHeart Failure Program

Maureen Carroll RN, CHFNHeart Failure Program Coordinator

December 9, 2013

University of California, San Francisco

• One of ten campuses in University of California system 

• Research intensive722 licensed beds; 28,000 admissions,

• average census = 523

• 39,000 Emergency visits

• Magnet Status 2012

•     

Gordon and Betty Moore Foundation Grant • $ 575,000 grant over two years (11/08 -2/11)

• 1 of 4 Bay Area Hospitals chosen

• In collaboration with Institute for Healthcare Improvement (IHI) and TCAB community

• Patients 65 years and older with a primary or secondary diagnosis of Heart Failure on 3 pilot units

Aim Statement for Grant

• Reduce 30 day readmissions by 30% for all cause heart failure patients 65 years and older – 2006 Data: 22.5%– Goal: 16%

• Reduce 90 day readmissions by 30% for all cause heart failure patients 65 and older– 2006 Data: 45.2%– Goal: 31%

The Heart Failure Program Team

• 1.6 FTE Heart Failure Program Coordinators– 7 day a week coverage

• Multidisciplinary Team– Includes Executive Leader, Hospitalists, Cardiologists,

Home Care RNs, Case Managers, Social Workers, Pharmacists, Dietician, Spiritual Care Chaplains, Educators- School of Nursing, Geriatric CNS, Med/Surg CNS, SNF representatives, PCPs, Outpatient Clinic NPs, Palliative care, Patient representative, Skilled Nursing Facility Representatives

IHI’s Key Changes forCreating an Ideal Transition Home

• Perform an Enhanced Assessment for Post-Hospital Needs

• Provide Effective Teaching and Facilitate Enhanced Learning

• Ensure Post-Hospital Care Follow-up

• Provide Real-Time Handover Communications

…and Communication is the Foundation

Heart Failure ProgramProfile of Our Patients

• ~ 2500 Admissions

• ~50 patients/month

• Average Age: 80 years – ( Recently expanded program to 18 years and older )

• Race:– White 45%, Asian 19%, African American 13%, Hispanic

5%, Other 18%

• Languages:– English ~ 70%, Cantonese 11%, Russian 8%, Spanish 5%,

Mandarin 2%, Other 6% (10+ languages represented)

2009: Inpatient Focused

2010: Outpatient Focused

2011: Sustainability & Community Collaboration

2012: Research & Expansion• HF patients >18 years and older ( July 2012)• 3 HF Studies

2013: Hospital Wide Readmission & Transition work• Started AMI program• Spread across service lines

Timeline of Heart Failure Program

The Cross-Continuum Team

The First Year ~ 2009 Was Inpatient Focused

• Monthly Heart Failure Grant Meetings with Multidisciplinary Team

• Comprehensive Patient Education - 4 languages

• Implemented IHI Evidence Based Interventions

• Developed Data Collection System

• Patient Advisory Group, Heart Healthy classes on unit

• Palliative Care Collaboration

• Trained Staff on Teach Back & HF Education

• Importance of the patient stories to drive change

Heart Failure Program: Interventions• Patient Identification- Daily Chart Reviews

• Extensive patient education (Teach Back method)

• Follow-up appointments- 7 days

• Follow-up phone calls – 72 hours

• Appropriate Referrals: Inpatient and Outpatient

• Core Measures

• Readmission Data collection, analysis and communication

• Focus on Continuum of Care - Communication and Collaboration

• In-services for staff, home care, skilled nursing

• Work with hospital wide projects to standardize and improve discharge process and decrease readmissions

The Second Year ~ 2010Was Outpatient Focused

• Collaboration with Outpatient Providers

– Skilled Nursing Facilities, Home Care Agencies, Primary Care Physicians and Cardiologists

– “Virtual Team” Email to connect providers (in/outpatient)

• Geriatric Transitions, Consultation, and Comprehensive Care (GeriTraCCC)

– MD House Calls for High Risk HF Patients (began Aug 2010)

• Heart Failure Clinic; High Risk NP appointments

• Palliative Care (ELNEC Trained)

• Senior Leadership Meetings

The Importance of Home Care

• First contact once at home

• What you are told in the hospital and what you see at home are often different

• Medication reconciliation- can’t underestimate the importance

• Barrier “ HOME-Bound” status

• Various different ways to interpret the law

• Decided to rely on HC to screen referrals for Home Care

HOME ALONE5%

HOME & FAMILY24%

HOME CARE46%

SNF/REHAB16%

DIED4%

HOSPICE3%

OTHER3%

Disposition of UCSF HF Patients 65+ 2009 - 2012

Data Collected from 2009-2012 of patients en-rolled in HF Program (1800+ pts)

Home Care referrals

Jan - May 09 July - Dec 09 Jan - June 10 July - Dec 10 Jan - June 11 July - Dec 11 Jan - June 12 July - Dec 12 Jan - June 13

HOME ALONE

0.0459183673469388

0.0664961636828645

0.05 0.0939226519337017

0.0689655172413793

0.0567375886524823

0.0420168067226891

0.0779220779220779

0.05

HOME & FAM-ILY

0.489795918367347

0.424552429667519

0.381818181818182

0.198895027624309

0.189655172413793

0.163120567375887

0.184873949579832

0.383116883116883

0.26875

HOME HEALTH/HOSPICE

0.464285714285714

0.51150895140665

0.568181818181818

0.707182320441989

0.741379310344828

0.780141843971631

0.773109243697479

0.538961038961039

0.68125

5%

15%

25%

35%

45%

55%

65%

75%

85%

Heart Failure Patients and Home Care

Axis Title

The Third and Fourth Year Research and Spread

• Research Studies

• Health e Heart study starting – – iPhones and avatar

• Automated Phone System• Expansion of Heart Failure Program- 18 years and

over

• Hospital Wide Readmission Work –

Heart Failure Program 2013

GeriTraCCC BEAT-HF Study

SNF Collaboration

Continuity of Care for Seriously Ill Work group

Discharge Follow Up Calls

Medicare FFS Workgroup

Excellence in Transitions

Healthy eHeart Study

Home Care Agencies

Transitions in AlignmentWorkgroup

Speaking Engagements

ARC

HF Team Meetings

HF/AMI Core

Measures

Patient Education

• Teach Back Technique

• Health Literacy Principles

• Same materials and technique across the Continuum of Care

• Educate patient regarding diagnosis, self –care management, and importance of follow up

• Lesson Learned: Listen before we teach. Ask open-ended questions

• Goal for Patient: Take action when you notice a change in your health

Teach Back Is Not Enough

In addition to Teach Back and Heart Failure

education, chronic diseases require life

style changes.

This requires: Time, Trust, Support

and Accountability

Email to Team on AdmissionDr. Smith (Inpatient Attending), Dr. Jones (Inpatient Resident), Dr. Moore (PCP), Dr. May(Cardiologist) Vicki (Home Care RN) and Lily (Case Manager RN) –

We just wanted to let you know that we will be following patient Bob Brown (MRN XXX) in the HeartFailure Program. This is Mr. Brown’s 5th admission in the past year and a 90 day readmission. I havemet with Mr. Brown and his daughter, Melanie today and reviewed HF education. We will continue tofollow them through post discharge phone calls. Please schedule a follow up appt with Dr. Moore(PCP) or his cardiologist, Dr. May, within one week as well as order Home Care RN with HF Protocol.

The Heart Failure program is for patients 65 and older who are admitted to the hospital with aprimary or secondary diagnosis of Heart Failure. Our program entails thorough patient educationon heart failure, follow-up phone calls after discharge, and assistance with other discharge planningneeds.

We encourage all physicians to order Nurse Home Care visits for HF patients at time of dischargeand to have a scheduled follow up appt with their PCP or Cardiologist within one week.

Our goal is to reduce readmissions and improve patient care. If we can help with any of theseplanning needs or answer any questions, please feel free to call us at 353-1897.

Thank you,Eileen Brinker, RNHeart Failure Program CoordinatorUCSF Medical Center

Readmission Interview

Multidisciplinary Rounds

• Quiet, private area

• Comprehensive team addressing patients needs

• Identification of high risk patients

• Next steps in care

• Reliably address risk of readmissions

• Home care liaison, chaplain,

Post Acute Care Follow-Up

• Follow-up calls – Within 7 Days (72 hrs) of discharge and by 14 days – Valuable time to troubleshoot

• Follow-up Appointments– Within 7 days for primary HF, otherwise within 14 days

• Home care encouraged for all HF patients

• Heart Failure Clinic NPs visits for high risk patients

• GeriTraCCC Program

• SNF Communication

Palliative Care with HF Patients

• Risk of sudden death means that palliative care must be integrated into care at every stage of illness

• Frequent exacerbations leading to re-admissions where palliative care can intervene

• Palliative care proven to improve symptoms, quality of life, satisfaction, and patient and family outcomes

• 25% of our Heart Failure patients die within one year• Up to one- half of deaths with Heart Failure are due to Sudden Death

• Palliative care prompts patients to think about all their options in the future and to start the important discussions for making plans

• Standard- consult on 3rd Readmission /Year

Pantilat and Steimle JAMA 2004;291:2476-82

Wright et al. JAMA 2008;300:1665-73

Morrison J Palliat Med 2005;8:S79-87

GeriTraCCC Program

• Geriatrics, Transitions, Consultation, and Comprehensive Care• Geriatrician provides home visits for high risk patients, works

with family, home health nurse, and providers • Criteria for referral:

– Multiple admissions in the past year– Missed appointments– Cognitive concerns– Medication concern– Palliative Care / Goals of Care– Caregiver adequacy concerns

• 70 Referrals over last 2 years

Dr. Helen Kao,

Medical Director

Systemic changes

• July 2013- Decreased age to 18 years and older for entire hospital-

• Outside company started to review inpatient vs. OBS status – • There a decrease in OBS patients resulting in an increase in IP

admissions and readmissions• Started AMI program• Restructuring of GeriTraCCC program resulted in temporary

decrease of High Risk referrals • Increase in Advanced Heart Failure Program

Next steps…

• Started readmission case review meetings with Cardiology MDs monthly

• Continuity Documentation Integrity nurses- meeting daily to ensure capturing appropriate patients

• Weekly meeting with Core Measure Quality nurses – assisting in process changes- EPIC, MD collaboration, Coders

• Merging with larger Transitions Group – Delivery System Reform Innovations in Population Health ( DSRIP)

• Spreading across service lines

• Continue collaboration with Quality Improvement Organization

• Continue work with community partners

Jan-

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30 Day ReadmissionsPrimary & Secondary Heart Failure

UCSF Medical Center Heart Failure Program

Goal Line: 16%

Annual Averages2009 = 24%2010 = 19%2011 = 13%2012 = 12%2013 = 18%

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50%90 Day Readmissions for Heart Failure Patients

Time Period

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Average for 2009 = 40%Average for 2010= 32%

Average for 2011 = 27% Average for 2012 = 26%Average for 2013 = 34%

Prelimi-nary

Keys to Success• Collaboration with IHI – essential at the start and guidance

throughout process• Dedicated Heart Failure Program Coordinators• Senior Leadership and Champions• Learn from Failures• Start before ready • Cohesive, committed Multidisciplinary Heart Failure Team • Palliative Care Team Collaboration• Outpatient program & Community Partners- Cross Continuum

Team• Results are not immediate – takes time to show improvement• Teach Back works – focus on Health Literacy• Power of the patient story to learn from and drive change

Photo used with permission and signed consent by the patient.

The Power of the Patient Story