Abstract

Background: Value is defined as health outcomes achieved per dollar spent over a cycle of care. Heart failure (HF) is an ideal condition for which to study value because 1 of 10 Veterans dies and 1 in 5 is readmitted within 30 days of discharge. “Home time,” defined as the time a patient spends alive and outside of health care institutions, is a novel outcome measure that is highly-prioritized among Veterans with HF. Yet variations in the value of care delivered by VA facilities during HF care episodes are unknown. A significant proportion of facility-level variations in value is likely explained by variations in the implementation of key care processes in the transition from HF hospitalization: HF medication optimization, early follow-up after discharge, and education regarding HF self-management. Yet gaps in VA HF transitional care persist: 2 of 3 Veterans eligible for guideline-recommended HF medications are not prescribed them, 2 of 3 do not attend a follow-up appointment within 7 days of discharge, and 2 of 5 feel ill-equipped in managing their disease process. How high-functioning VA facilities (with high home time and low costs) successfully deliver HF transitional care and social-organizational factors influencing practice adoption are unknown. There is a need to test implementation strategies to establish HF transitional care practices. Facilitation is a strategy whereby skilled individuals work with key stakeholders to select evidence-based practices and implementation strategies, adapt them to the local context, and assist in intervention implementation. Audit and feedback can complement facilitation by providing data on whether intervention and implementation goals are being achieved and stimulating appropriate intervention and implementation adaptations. However, the feasibility of using facilitation and audit and feedback to enhance adoption of evidence-based practices related to HF transitional care at low-functioning VA facilities (with low home time and high costs) is unknown. Significance: This proposal supports the vision of VA leadership by studying health care value improvement and implementation strategies to support care coordination of chronic diseases at facilities with low quality of care. It has the potential to improve rates of mortality and readmission after HF discharge (key SAIL metrics). Innovation: Novelty in Aim 1 centers on the application of the value framework to HF transitional care and the focus on home time. Novelty in Aim 2 revolves around characterizing evidence-based practices related to HF transitional care, how they were implemented, and factors influencing their implementation within the context and culture of the VA. Novelty in Aim 3 lies in the use of facilitation and audit and feedback to implement an evidence-based intervention for patients with a complex chronic disease at low-functioning facilities. Specific Aims: 1. Value Assessment: In a national cohort of Veterans hospitalized with HF, assess facility- level variations in guideline-concordant HF transitional care, risk-adjusted home time and risk-standardized costs of care within 90 days of discharge and the association between guideline-concordant care and value. 2. Context Assessment: Conduct multi-level informant interviews at outlier facilities (4 high-performing, 2 intermediate-performing, and 2 low-performing) to characterize evidence-based practices shown to work in VA context, how they were implemented, and social-organizational factors influencing practice adoption. 3. Implementation Feasibility: Pilot-test facilitation and audit and feedback as strategies to implement an intervention consisting of evidence-based HF transitional care practices observed to work in VA context in Aim 2 at 2 low-performing facilities and assess the intervention’s implementation, reach, and cost. Methodologies: The above aims will be achieved by means of value measurement and health economics (Aim 1), qualitative interviewing methods (Aim 2), and implementation and dissemination science (Aim 3). Next Step: We will perform a type III implementation-effectiveness hybrid trial at a wider array of facilities to compare the effect sizes and costs of audit and feedback versus facilitation combined with audit and feedback.

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DRA: Health Systems Science, Cardiovascular Disease

DRE: TRL - Applied/Translational, Technology Development and Assessment, Treatment - Implementation

Keywords: Best Practices

MeSH Terms: None at this time.