J Clin Pathways. 2018;4(2):30-32.
A Heart Failure Clinical Pathway to Reduce Hospital Readmissions
As the US health care system shifts to a value-based care system, quality of care will have a direct impact on reimbursement. Indeed, the Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program (HRRP)4 has increased the urgency for initiatives, interventions, and care models that will truly curb readmissions and lower health care costs. While guidelines for care are available and consistently updated, unfortunately, many patients with HF are not receiving optimal care as recommended by clinical guidelines.5
Clinical pathways provide a means of implementing the most up-to-date guidance into clinical settings in order to improve the value and efficiency of the care provided. As you will learn later in this interview, the use of clinical pathways and clinical decision support tools in the management of HF is not a new trend. There is already a growing amount of research proving the effectiveness of clinical pathways for enhanced HF management, including in the reduction of readmission rates as well as costs.
To better understand how clinical pathways are developed and executed in cardiovascular care, Journal of Clinical Pathways spoke with Travis B Wasserman, MPH; Thomas F Spiegel, MD; and Corey E Tabit, MD, MBA, MPH, from University of Chicago Medicine (Chicago, IL), who developed a multifaceted Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with HF.6 The pathway, along with several interventions, was implemented directly into the emergency department (ED) to increase its impact. They explain the development of the pathway, challenges to implementation, and the general use of clinical pathways in HF management and cardiovascular care.
Can you briefly describe your study?6 What motivated you to consider a clinical pathway for the management of HF? Is the overutilization of ED resources a significant concern for HF patients?
Dr Spiegel: There were multiple reasons to develop this pathway—some global and some local. The global reasons involve the significant impact that ADHF has on patients: (1) it is the leading diagnosis for inpatients over age 65; (2) it is the most common reason for hospitalization and rehospitalization in the United States; (3) it continues to lead to poor patient experiences; and (4) there are potentially severe financial implications from failure of quality care within this population (eg, CMS penalize centers with excessive 30-day rehospitalizations).4 Local reasons include the fact that underserved patients are disproportionately affected by all of the above global impacts. Additionally, as target rehospitalization rates are not adjusted for social disparities, penalties are imposed disproportionately on centers that care for underserved patients.
These local and global reasons motivated the development of the HF pathway at our center, University of Chicago Medicine (UCM), which is a tertiary care center on Chicago’s South Side—one of the poorest and most violent regions of the city. Here, attempts to reduce rehospitalizations have had varying success, especially in low-socioeconomic urban patients. These patients consume disproportionately more health care resources than more affluent patients and often overutilize the ED for their care, leading to fragmented care and elevated health care costs.
Beginning in January 2015, we decided to treat patients at our center with ADHF according to a multidisciplinary ADHF clinical pathway developed in accordance with the 2013 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Management of Heart Failure.7 Patients received standardized education while admitted and received early outpatient follow-up after discharge. In addition, patients who returned to the ED after discharge received early consultation with a cardiologist.
The ED was concerned that this pathway would lengthen patients’ length of stay, as the consulted cardiologist would encourage diuresis in the ED. The ED envisioned their hallways running yellow with ADHF diuresis and were concerned that, after a prolonged attempt at diuresis, the patients would ultimately be admitted and would have increased the burden on the ED staff and other patients without reducing readmissions. The potential benefit of more inpatient beds by not admitting ADHF patients was the allure to the ED, as UCM’s inpatient bed occupancy is often 100%. We were pleased to report5 that this pathway reduced readmissions without increasing the ED’s length of stay, improved outpatient follow-up, and led to the ED’s ability to admit other non-ADHF patients to the hospital when patients would have otherwise been boarded in the ED.
Dr Tabit: Many of the patients we care for use the ED for their primary care. While this is arguably not an appropriate use of the ED, we felt it best to design an intervention that conformed to patients’ real use (or misuse) of the health system. By partnering with our colleagues in the ED, we were able to use ED resources more efficiently, which resulted in more patients safely discharged without increasing the work burden on the ED.
Please describe the development process of the ADHF clinical pathway (ADHFCP). What were some of the challenges to successful development and implementation?
Dr Spiegel: The development and success of this pathway is attributable to the passion, collaboration, and dedication to improving patient care that this multidisciplinary team rallied around and still maintains to this day. We included members from areas including cardiology, emergency medicine, inpatient and clinic (registered nurses), pharmacy, nutrition, physical and occupational therapy, social work, case management, the quality department, and senior administration. “It takes a village” has been the phrase repeated whenever the team convenes. Some of the key insights we gained during this process was that (1) planning for transitions of care was critical; (2) addressing the unique factors specific to our patient population was important (eg, many did not have scales so we bought them scales, if transportation was an issue we arranged for transportation, etc); and (3) early treatment and disposition planning in the ED between the ED physicians and cardiologists led to increased prompt outpatient follow-up visits as opposed to inpatient stays.
Dr Tabit: The multidisciplinary nature of this intervention was really crucial. In the past, many of our patients were readmitted for reasons that directly stemmed from social problems such as housing instability or lack of transportation. By working together across disciplines, we could ensure that potential causes for readmission were discovered and addressed early in the index admission. If the patient returned to the ED anyway, the multidisciplinary response team could correct further issues quickly and often facilitate a safe discharge with close outpatient follow-up.