UCSF Medical Center Heart Failure Program - IHI …app.ihi.org/Events/Attachments/Event-2469/Document-3321/UCSF_Case...UCSF Medical Center Heart Failure Program Maureen Carroll RN,

Institute for Healthcare Improvement

Reducing Avoidable Readmissions Seminar4/9/2014

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UCSF Medical CenterHeart Failure

Program

Maureen Carroll RN, CHFNTransitional Care Manager

Heart Failure Program Coordinator

April 23, 2014

University of California, San Francisco

• Mission : The reason that we exist is Caring, Healing, Teaching, and Discovery

• Top 10 Hospitals ( US World and News)

• 722 licensed beds; 28,000 admissions,

average census = 523

• 7,000 employees; 2,000 MDs

• Magnet status



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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%



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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

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 teaching

2014: Quality Division

Disease Management Program – Medicare focus

Timeline of Heart Failure Program



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Profile of Our Patients

• > 3000 Admissions

• ~40 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)

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



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The First Year ~ 2009 Was Inpatient Focused

• Monthly Heart Failure Grant Meetings with Multidisciplinary Team

• Comprehensive Patient Education

• 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

• Shared patient stories to drive change

Heart Failure Program: Interventions

• Patient Identification- Daily Chart Reviews

• Extensive patient education (Teach Back method)

• Follow-up appointments

• Follow-up phone calls

• Referrals: Inpatient and Outpatient

• Readmission Data collection and Analysis

• 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 readmission projects



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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 Collaboration

• Senior Leadership Meetings

HOME ALONE

5%

HOME & FAMILY23%

HOME CARE46%

SNF/REHAB16%

DIED4%

HOSPICE3%

OTHER3%

Disposition of UCSF HF Patients 65+ 2009 - 2012

Data Collected from 2009-2012 of patients

enrolled in HF Program (1800+ pts)



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The importance of Home Care

• Medication reconciliation- can’t underestimate the importance

• Reinforce what was started in the hospital

• Accountability

• Focus on self management skills

• Relationship building and Trust

• Overcoming Barriers “Homebound” status

• Relationship building and trust

The Third Year ~ 2011Sustainability & Collaboration

• HF Readmission Taskforce

• Moore Grant completed, HF Program funded by Medical Center

• Continued work with Outpatient Providers

– HF NP Outpatient visits for high risk patient & GeriTraCCC

– Increased collaboration with SNF and Community agencies



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The Fourth Year ~2012 Research and Spread

• Research Studies

• Expansion of Heart Failure Program- 18 years and over

• Improved Multidisciplinary rounds

• Hospital Wide Readmission Work

• Community Outreach

Patient Education

• Teach Back Technique

• Health Literacy Principles

• Four languages, use of interpreter

• Input from patients and caregivers

• 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



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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

Readmission Interview



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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 day

• Heart Failure Clinic NPs visits for high risk patients

• Home Visits Programs

– ( MD/NP/Social workers)

• Hand off Communication Outpatient providers

Real-Time Handover Communications

• “Warm Hand-overs” to Skilled Nursing Facilities, Home care agencies, outpatient clinics and providers

• Medication Reconciliation

– Increasing Pharmacist consults on discharge

– Discharge summary at discharge

– EPIC Journey

• Email-notifications to inpatient team, case manager, consultants, HF clinic, home care RNs, SNF and PCP on admission

– Creates a “Virtual Care Team”

– Time consuming but valuable

– Unites the entire team working on transition of care



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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 Heart

Failure Program. This is Mr. Brown’s 5th admission in the past year and a 90 day readmission. I have

met with Mr. Brown and his daughter, Melanie today and reviewed HF education. We will continue to

follow 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 a

primary or secondary diagnosis of Heart Failure. Our program entails thorough patient education

on heart failure, follow-up phone calls after discharge, and assistance with other discharge planning

needs.

We encourage all physicians to order Nurse Home Care visits for HF patients at time of discharge

and 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 these

planning needs or answer any questions, please feel free to call us at 353-1897.

Thank you,

Eileen Brinker, RN

Heart Failure Program Coordinator

UCSF Medical Center

Palliative Care with HF Patients

• 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

• Increased palliative care options in outpatient setting- expansion

Pantilat and Steimle JAMA 2004;291:2476-82

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

Morrison J Palliat Med 2005;8:S79-87



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0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

30 Day ReadmissionsPrimary & Secondary Heart Failure

UCSF Medical Center Heart Failure Program

Goal Line:

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

Heart Failure Program Changes• July 2013- Decreased age to 18 years and older for entire

hospital-

– 40% of Heart Failure patients under 65-

– Unique population- Large substance abuse population, congenital HF, advanced heart failure patients

• 2014 – SPREAD, SPREAD, SPREAD

• Quality Division

– Heart Failure, AMI, COPD, PNA Medicare patients 65 and older

– Increased Outpatient Focus

– Multiple new Improvement/Transitions projects

• NP/social worker home visits for Medicine Division, expansion of GeriTraCCC program, Care Coordinators

• Increased Palliative Care program

• Full support Executive Leadership

• Centralized Follow UP Calls program- goal- all discharged patients

• Increased Access



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Lessons Learned

• Collaboration with IHI – essential at the start and guidance throughout process

• Dedicated Heart Failure/ Disease Management Program Coordinators

• Senior Leadership and Champions necessary

• Cohesive, committed Multidisciplinary Heart Failure Team

• Palliative Care Team Collaboration

• Outpatient program & Community Partners essential

• 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

Documents

UCSF Medical Center Heart Failure Program - IHI …app.ihi.org/Events/Attachments/Event-2469/Document-3321/UCSF_Case...UCSF Medical Center Heart Failure Program Maureen Carroll RN,