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Implementation of the Hospital to Home (H2H) Heart failure Initiative
Paul A. Heidenreich, MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: May 2010 - April 2013
Heart failure is the primary reason for discharge from the VA medical service. The cost of caring for these patients is quite high, with Medicare paying $1,100-$1,800 per patient per month in 2003, primarily for inpatient care. Furthermore, the readmission rate is high, approximately 20% at 30 days, suggesting the need for an improved transition of care from inpatient to outpatient. Accordingly, the Joint Commission and the VA are considering adopting performance measures for heart failure readmission, and the Center for Medicare and Medicaid Services has released risk-adjusted heart failure readmission rates for all nonfederal U.S. hospitals in the summer of 2009.
Many have considered the transition from inpatient to outpatient care as a promising target for improving care and readmission rates for heart failure. It is known that patients frequently do not remember in-hospital instructions and often take inappropriate medications or doses when they get home. Many are not seen in a timely manner following discharge and opportunities for early detection of deterioration are lost. These issues are addressed by the Hospital to Home initiative of the Institute for Health Care Improvement (IHI) and the American College of Cardiology (ACC). The Hospital to Home (H2H) Excellence in Transitions Initiative is a new national campaign to reduce preventable readmissions for patients recently hospitalized with a cardiovascular condition (www.H2Hquality.org).
The primary objectives of the proposed Service Directed Project are three fold:
1) To determine if VA facility enrollment in H2H results in improved care for VA patients with heart failure. (H2H Impact Sub-study)
2) To determine barriers and facilitators to a) enrolling facilities in H2H, and for those facilities enrolled, b) adopting the H2H interventions. (Formative Evaluation Sub-study)
3) To evaluate the use of the VA Heart Failure Network to aid in implementing the H2H initiative in a randomized trial. (HF Network Facilitation Sub-Study).
Our research plan includes three sub-studies addressing each of the three specific aims. An H2H impact/summative evaluation (Specific Aim 1) will be the first sub-study, where hospitals that enrolled in the program will be compared to facilities that did not enroll in H2H.
Outcomes for this evaluation include process of care measures (including performance measures), readmission rates, and mortality. The second sub-study will be a formative evaluation of the implementation process of H2H for those enrolled in H2H (Specific Aim 2).
We will examine facilitators and barriers to enrolling in H2H, and once enrolled, to pursuing the H2H goals and recommended steps. The third sub-study will be a randomized trial of activation of the VA Heart Failure Network to facilitate H2H enrollment (Specific Aim 3): While the primary endpoint for this trial for Specific Aim 3 will be H2H enrollment, we will also examine if process of care measures or outcomes are better among those randomized to facilitation.
The Heart Failure (HF) Network, the VA H2H initiative was launched in January 2010. Initially, a total of 122 VA facilities with <100 discharges in 2008-2009 were randomized into intervention and control groups. From Month 1 through month 6 the implementation of the VA H2H initiative was facilitated for all the intervention facilities. We had 2 web-based meetings to announce this initiative followed by e-mails and tool-kits to get support from local leadership. Members at these facilities were asked to nominate local opinion leaders. This link provides details and tools provided to members: http://www.queri.research.va.gov/chf/products/h2h/
All the intervention facilities were asked to participate by (1) enrolling their facility at the H2H website as commitment to, and (2) initiating projects based on the VA H2H initiative. In Month 6 surveys were sent to both the intervention and control facilities to assess participation in the VA H2H initiative. From Month 7 to Month 12 the VA H2H inititiative is being facilitated at all remaining 61 control facilities.
At the end of the initial 6 month intervention period 54% of 61 facilities in the intervention arm had enrolled in H2H compared to 10% of 61 control facilities (P<0.001). After an additional 6 months that targeted the control facilities with the intervention a total of 66 facilities had enrolled (37 in the initial intervention and 29 in the initial control group.
By 24 months 80 VA facilities had enrolled reporting 529 programs ongoing or planned addressing the 3 H2H target areas (medication during transition of care, early follow-up, and symptom recognition). 319 of the projects predated the initiation of H2H, 117 were started as a result of H2H, and 93 were being planned as a result of H2H.
H2H Enrollment versus no enrollment.
We had 18 months of follow up data on 77 facilities that enrolled in H2H and compared these to 39 that did not enroll. There were no significant differences (p>=0.05) between facilities that did and did not enroll in mean bed size (373 vs 372) heart failure discharges in 2009 (240 vs 213) average heart failure patient age (71 vs 71 years), and mean length of stay (5.2 vs. 5.2 days). There were also no statistically significant differences in region of the country, Joint Comission accreditation, Council on Teaching Hospital membership and presence of accredited graduate medical education programs. However, VA facilities that enrolled in H2H were more likely to be tertiary care facilities (49% vs. 28%, p=0.03) have a cardiac catheterization laboratory (76% vs 52%, p=0.009) and report using home monitoring for heart failure patients (73% vs 42%, p=0.004) than facilities that did not enroll.
Before our project started the mean 30 day readmission rate was 21% +/- 4% (standard devision) for facilities that later enrolled compared to 21% +/- 3% for facitilies that did not eventually enroll.
The primary outcome (30-day all cause readmission) after H2H enrollment was no different between those that enrolled (20% +/- 5%, mean percentage SD) and facilities that did not enroll in H2H (19% +/- 6%, p=0.73). However a secondary outcome (1-year total hospital days post discharge) was significantly lower in those that enrolled in H2H (7.2 +/- 2.9 days) compared to those not enrolled (9.2 +/- 3.0 days, p=0.002). 30-day mortality was not statistically different between the groups: 6.0% +/- 2.9% if enrolled vs. 5.5% +/- 3.0% if not enrolled (p=0.58).
One of the process of care measures that was a focus of H2H was 7 day follow-up following dischage.
This was higher, though not statistically significant in the facilities that enrolled in H2H (13.2% vs. 11.7% p=0.29).
However, 7-day follow-up (face-to-face in cardiology clinic) was signficantly greater in those facilities that enrolled in H2H (3.1% vs. 2.0% , p=0.04). This is liklely due to the fact that many providers in the VA Heart Failure Network (physicians and nurses) are affiliated with cardiology clinics.
We identified several barriers and facilitators to H2H enrollment and these included lack of additional staff (FTE). Such financial support was only provided by 15% of facilities that ultimately enrolled in H2H. Space was provided by over 50% of facilities. Given these administrative barriers, having a local champion was an important facilitator since many were asked to conduct the project on top of their existing duties. We found that cost at the Central Office level was a minimal barrier as we were able to perform our implementation at a cost of $10,200.
The project demonstrates that a provider network (such as the HF Network) can be used to increase enrollment in a national quality improvement initiative with minimal resource use.
In addition the project has contributed to over half of the inpatient VA facilities (80) enrolling in H2H.
Based on these findings we have planned additional interventions that can be promoted through the VA Heart Failure Network.
However the project did not show that Hosptial to Home Initiative itself led to reduced admission rates which was the primary goal of the national H2H program. We did show that another metric may be more valuable and that is total hospital days following discharge which were reduced when measured over a 12 month period following enrollment in H2H.
Thus, the nominal yes/no description of readmission may not represent the true burden of disease or the effect of programs designed to keep patients out of the hospital
These data have been discussed with the national H2H leadership and they are evaluating different aspects of the H2H to determine some should be emphasized over others.
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DRA: Health Systems, Cardiovascular Disease
DRE: Treatment - Observational
Keywords: Cardiovasc’r disease, Care Management
MeSH Terms: none