1. 5/1/2015 Hudson Valley Hospital Center Heart Failure Project A collaborative approach to improving heart failure care

2. 5/1/2015 Hospital to Home (H2H) A national quality improvement initiative A national quality improvement initiative Sponsored by the American College of Cardiology (ACC) and the Institute of Healthcare Improvement (IHI) Sponsored by the American College of Cardiology (ACC) and the Institute of Healthcare Improvement (IHI) Purpose: to reduce cardiovascular-related hospital readmissions & improve transitional care from hospital to home Purpose: to reduce cardiovascular-related hospital readmissions & improve transitional care from hospital to home Strategic partnerships are encouraged as a vehicle for improving care and outcomes Strategic partnerships are encouraged as a vehicle for improving care and outcomes

3. 5/1/2015 HVHC Heart Failure Task Force Purpose: To improve the care delivered to heart failure patients across the continuum

4. 5/1/2015 Members of the HVHC HF Task Force Myrna Cuevas RN, Esq Myrna Cuevas RN, Esq William Higgins MD William Higgins MD Maggie Adler RN-C Maggie Adler RN-C Jennifer Fell RD Jennifer Fell RD Ann Marie Beall DPh Ann Marie Beall DPh Visiting Nurse Association of Hudson Valley Visiting Nurse Association of Hudson Valley

5. 5/1/2015 ACE Star Model

6. ACE Star Model & EBP Process PICO Question: What interventions for heart failure patients help decrease their rehospitalization and mortality rates? What interventions for heart failure patients help decrease their rehospitalization and mortality rates? 5/1/2015

7. Knowledge Discovery & Evidence Summary

8. 5/1/2015 Facts on Heart Failure 50% readmission rate within 6 months 50% readmission rate within 6 months 25% to 35% incidence rate of death at 12 months 25% to 35% incidence rate of death at 12 months

9. 5/1/2015 Facts on Heart failure The mortality rate for women with breast cancer is 1 in every 29 deaths, the mortality rate for women with cardiovascular disease is 1 in every 2.4 deaths The mortality rate for women with breast cancer is 1 in every 29 deaths, the mortality rate for women with cardiovascular disease is 1 in every 2.4 deaths

10. 5/1/2015 Trends in Hospitalization for Heart Failure by Age Group 1979-2004 (CDC, 2006)

11. 5/1/2015 CMS Quality Measures: Heart Failure (HF) 100% compliance with the following evidenced-based guidelines: Discharge instructions Discharge instructions  diet  MD f/u  weight monitoring  worsening s/s  Medications with reconciliation Left ventricle systolic function evaluation Left ventricle systolic function evaluation ACEI/ARB for LVSD ACEI/ARB for LVSD Smoking cessation counseling Smoking cessation counseling

12. 5/1/2015 Heart Failure at HVHC Heart failure is the second highest DRG Heart failure is the second highest DRG Average costs per patient per day $2,000 Average costs per patient per day $2,000 Average LOS is 6 days Average LOS is 6 days 30 day readmission rate is 24.2%, national rate is 24.5% (HHS, 2008) 30 day readmission rate is 24.2%, national rate is 24.5% (HHS, 2008) Mortality rate is 9.7%, nationally it is 11.1% (HHS, 2008) Mortality rate is 9.7%, nationally it is 11.1% (HHS, 2008)

13. 5/1/2015 Translation into practice Clinical Expertise to translate your findings into practice

14. 5/1/2015 How can we improve practice? Standardize treatment plans for heart failure Standardize treatment plans for heart failure Standardize patient education for heart failure Standardize patient education for heart failure Case Management referral for heart failure patients to Telehealth program at VNA Case Management referral for heart failure patients to Telehealth program at VNA Collaborate with the Visiting Nurse Association of Hudson Valley (VNA) Collaborate with the Visiting Nurse Association of Hudson Valley (VNA) Collaborate with community based physicians Collaborate with community based physicians

15. 5/1/2015 Integration Integrating your findings into practice

16. 5/1/2015 Standardize Treatment Evidenced-basedRecommendationspromote a reduction in rehospitalization and mortality for patients with heart failure (IHI, AHRQ, ACC) Physician Order Set LVSF assessment LVSF assessment ACEI or ARBs ACEI or ARBs Beta Blockers Beta Blockers Anticoagulants for atrial fibrillation Anticoagulants for atrial fibrillation Diuretics Diuretics Lab assessment Lab assessment Influenza & Pneumoccocal vaccination Influenza & Pneumoccocal vaccination Diet and fluid restriction Diet and fluid restriction Daily weights Daily weights Exercise/activity tolerance Exercise/activity tolerance Smoking cessation counseling Smoking cessation counseling Patient education Patient education Case management & Nutrition referral Case management & Nutrition referral (ACCF/AHA, 2009; AHRQ, 2009) (ACCF/AHA, 2009; AHRQ, 2009)

17. 5/1/2015 Considerations in Treatment of Special Populations Elderly patient's have an altered ability to metabolize or tolerate medication therapy Elderly patient's have an altered ability to metabolize or tolerate medication therapy Isosorbide dinitrate and hydralazine is recommended for African-Americans in addition to standard heart failure treatment Isosorbide dinitrate and hydralazine is recommended for African-Americans in addition to standard heart failure treatment 50% of Asian patients develop a ACEI induced cough 50% of Asian patients develop a ACEI induced cough Majority of patient’s with heart failure are women Majority of patient’s with heart failure are women

18. 5/1/2015 Standardize Patient Education Provide education literature from the AHA Provide education literature from the AHA Document education completed in EHR Document education completed in EHR Revise Discharge Instruction sheet to include HF care instructions Revise Discharge Instruction sheet to include HF care instructions HF education reinforced by VNA nurses HF education reinforced by VNA nurses Future: Future: In CPOE create notification link from physician order for HF education to nurses task list In CPOE create notification link from physician order for HF education to nurses task list

19. 5/1/2015 Heart Failure (HF) Screening Flow Chart Present to ED Case Manager assesses patient for homecare or skilled nursing need. Y N No Health Care Services Provided N Homecare or skilled nursing referral made Y Case management evaluates patient/ Family/caregiver’s goals Collaborates discharge plan with patient and health care team HF symptoms w/i 1 year and/or present HF symptoms and/or R/A 31 days with previous HF diagnosis Admit as Inpatient

20. 5/1/2015 Telehealth Program Screening for eligibility will be performed by the VNA while the patient is hospitalized Screening for eligibility will be performed by the VNA while the patient is hospitalized Remote home monitoring will include vital signs, oxygen level assessment, and weight Remote home monitoring will include vital signs, oxygen level assessment, and weight Patient education provided by VNA nurses will reinforce education provided by HVHC nurses Patient education provided by VNA nurses will reinforce education provided by HVHC nurses Telehealth visits are in addition to regular home nursing visits Telehealth visits are in addition to regular home nursing visits

21. 5/1/2015 Accomplishments & Outcomes of the Heart Failure Project Interdisciplinary approach Interdisciplinary approach Physician Order Set Physician Order Set Patient Education Patient Education Comprehensive discharge instructions Comprehensive discharge instructions Telehealth program Telehealth program Collaboration across the continuum of care Collaboration across the continuum of care Increase in patient self- management skills Increase in patient self- management skills Increase in patient satisfaction Increase in patient satisfaction Decrease variation in care delivered Decrease variation in care delivered Decrease LOS from 6 to 4 days Decrease LOS from 6 to 4 days Decrease 30 day readmissions to 16% Decrease 30 day readmissions to 16% Decrease mortality by 10% Decrease mortality by 10%

22. 5/1/2015 Evaluation Evaluation HF Readmission & Mortality rates

23. 5/1/2015 Heart Failure Readmissions Heart Failure Task Force Update: Total 27 HVHC patients referred to Visiting Nurse Association Hudson Valley in 10 months (9/09 – 06/10) Total 27 HVHC patients referred to Visiting Nurse Association Hudson Valley in 10 months (9/09 – 06/10) –Readmission rate: 11% –HVHC Goal: 16%

24. 5/1/2015 Future Opportunities for Collaboration

25. 5/1/2015 Improving Care at HVHC At HVHC we are dedicated to caring for our patients across the continuum……. At HVHC we are dedicated to caring for our patients across the continuum…….

26. 5/1/2015 References Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP: ACE Star Model of EPB: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. Retrieved July 8, 2009, from http://www.acestar.uthscsa.edu Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP: ACE Star Model of EPB: Knowledge Transformation. The University of Texas Health Science Center at San Antonio. Retrieved July 8, 2009, from http://www.acestar.uthscsa.edu http://www.acestar.uthscsa.edu Centers for Disease Control and Prevention. (2006). Heart Failure Fact Sheet. Retrieved August 16, 2009, from the CDC on the World Wide Web: http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf Centers for Disease Control and Prevention. (2006). Heart Failure Fact Sheet. Retrieved August 16, 2009, from the CDC on the World Wide Web: http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/American heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10 &RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FI RSTINDEX=0&resourcetype=HWCIT Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2005). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: A report of the American College of Cardiology/American heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10 &RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FI RSTINDEX=0&resourcetype=HWCIT http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10 &RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FI RSTINDEX=0&resourcetype=HWCIT http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10 &RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FI RSTINDEX=0&resourcetype=HWCIT Institute for Healthcare Improvement (2008). 5 Million Lives. Getting started kit: Improved care for the patients with congestive heart failure. Retrieved July 19, 2009, from IHI on the World Wide Web: http://www.ihi.org Institute for Healthcare Improvement (2008). 5 Million Lives. Getting started kit: Improved care for the patients with congestive heart failure. Retrieved July 19, 2009, from IHI on the World Wide Web: http://www.ihi.orghttp://www.ihi.org

27. 5/1/2015 References Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2009). 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology foundation/American Heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFO RMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al. (2009). 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology foundation/American Heart Association Task Force on Practice Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFO RMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFO RMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFO RMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT National Guideline Clearinghouse. (2007). Heart Failure in Adults. Retrieved July 20, 2009, from NGC on the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+A ND+Failure National Guideline Clearinghouse. (2007). Heart Failure in Adults. Retrieved July 20, 2009, from NGC on the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+A ND+Failure http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+A ND+Failure http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+A ND+Failure Schroetter, S. A., & Peck, S. D. (2008, April). Women’s risk of heart disease: Promoting awareness and prevention-a primary care approach. MEDSURG Nursing, 17(2), 107-113. Schroetter, S. A., & Peck, S. D. (2008, April). Women’s risk of heart disease: Promoting awareness and prevention-a primary care approach. MEDSURG Nursing, 17(2), 107-113. U. S. Department of Health and Human Services. (2009). Hospital Compare-A quality tool provided by Medicare. Retrieved July 19, 2009, from HHS on the World Wide Web: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE %7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home U. S. Department of Health and Human Services. (2009). Hospital Compare-A quality tool provided by Medicare. Retrieved July 19, 2009, from HHS on the World Wide Web: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE %7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE %7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE %7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home