UCSF Medical Center Heart Failure Program

Maureen Carroll RN, CHFN Heart Failure Program Coordinator December 9, 2013

University of California, San Francisco

• • • • • One of ten campuses in University of California system Research intensive722 licensed beds; 28,000 admissions, average census = 523 39,000 Emergency visits Magnet Status 2012

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%

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

IHI’s Key Changes for Creating 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

Heart Failure Program Profile of Our Patients

• • • • • ~ 2500 Admissions ~50 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)

Timeline of Heart Failure Program

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 program • Spread across service lines

The Cross-Continuum Team

The First Year ~ 2009 Was Inpatient Focused

• • • • • • • • Monthly Heart Failure Grant Meetings with Multidisciplinary Team Comprehensive Patient Education - 4 languages 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 Importance of the patient stories to drive change

Heart Failure Program: Interventions

• • • • • • • • • • Patient Identification- Daily Chart Reviews Extensive patient education (Teach Back method) Follow-up appointments- 7 days Follow-up phone calls – 72 hours Appropriate Referrals: Inpatient and Outpatient Core Measures Readmission Data collection, analysis and communication 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 decrease readmissions

The Second Year ~ 2010 Was 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 (ELNEC Trained) Senior Leadership Meetings

The Importance of Home Care

• First contact once at home • What you are told in the hospital and what you see at home are often different • • Medication reconciliation- can’t underestimate the importance Barrier “ HOME-Bound” status • Various different ways to interpret the law • Decided to rely on HC to screen referrals for Home Care

Disposition of UCSF HF Patients 65+ 2009 - 2012

HOSPICE 3% OTHER 3% DIED 4% HOME ALONE 5% SNF/REHAB 16% HOME & FAMILY 23% HOME CARE 46%

Data Collected from 2009-2012 of patients enrolled in HF Program (1800+ pts)

Home Care referrals

Heart Failure Patients and Home Care 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HOME ALONE HOME & FAMILY HOME HEALTH/HOSPICE Jan - May 09 July - Dec 09 Jan - June 10 July - Dec 10 Jan - June 11 July - Dec 11 5% 49% 46% 7% 42% 51% 5% 38% 57% 9% 20% 71% 7% 19% 74% 6% 16% 78% Jan - June 12 4% 18% 77% July - Dec 12 Jan - June 13 8% 38% 54% 5% 27% 68%

The Third and Fourth Year Research and Spread

• Research Studies • Health e Heart study starting – – iPhones and avatar • Automated Phone System • Expansion of Heart Failure Program- 18 years and over • Hospital Wide Readmission Work –

ARC GeriTraCCC BEAT-HF Study Speaking Engagements SNF Collaboration Continuity of Care for Seriously Ill Work group Discharge Follow Up Calls HF/AMI Core Measures Home Care Agencies Heart Failure Program 2013 Transitions in Alignment Workgroup Medicare FFS Workgroup HF Team Meetings Excellence in Transitions Healthy eHeart Study

Patient Education

• Teach Back Technique • Health Literacy Principles • 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

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

Email to Team on Admission

Dr. 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 5 th 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

Readmission Interview

Multidisciplinary Rounds

• • • • • • Quiet, private area Comprehensive team addressing patients needs Identification of high risk patients Next steps in care Reliably address risk of readmissions Home care liaison, chaplain,

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 days Home care encouraged for all HF patients Heart Failure Clinic NPs visits for high risk patients GeriTraCCC Program SNF Communication

Palliative Care with HF Patients

• • • • • • • Risk of sudden death means that palliative care must be integrated into care at every stage of illness Frequent exacerbations leading to re-admissions where palliative care can intervene 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 3 rd Readmission /Year

GeriTraCCC Program

• • • • Geriatrics, Transitions, Consultation, and Comprehensive Care Geriatrician provides home visits for high risk patients, works with family, home health nurse, and providers Criteria for referral: – Multiple admissions in the past year – Missed appointments – Cognitive concerns – Medication concern – Palliative Care / Goals of Care – Caregiver adequacy concerns 70 Referrals over last 2 years

Dr. Helen Kao, Medical Director

Systemic changes

• July 2013- Decreased age to 18 years and older for entire hospital • • • • • Outside company started to review inpatient vs. OBS status – There a decrease in OBS patients resulting in an increase in IP admissions and readmissions Started AMI program Restructuring of GeriTraCCC program resulted in temporary decrease of High Risk referrals Increase in Advanced Heart Failure Program

Next steps…

• Started readmission case review meetings with Cardiology MDs monthly • Continuity Documentation Integrity nurses- meeting daily to ensure capturing appropriate patients • Weekly meeting with Core Measure Quality nurses – assisting in process changes- EPIC, MD collaboration, Coders • Merging with larger Transitions Group – Delivery System Reform Innovations in Population Health ( DSRIP) • Spreading across service lines • Continue collaboration with Quality Improvement Organization • Continue work with community partners

40,0% 35,0% 30,0% 25,0% 20,0% Goal Line: 16% 15,0% 10,0% 5,0% 0,0%

30 Day Readmissions Primary & Secondary Heart Failure UCSF Medical Center Heart Failure Program

Annual Averages

2009 = 24% 2010 = 19% 2011 = 13% 2012 = 12% 2013 = 18%

30% 25% 20% 15% 50% 45% 40% 35% 90 Day Readmissions for Heart Failure Patients

Average for 2009 = 40% Average for 2010= 32% Average for 2011 = 27% Average for 2012 = 26% Average for 2013 = 34%

Preliminary

Time Period

• • • • • • • • • • •

Keys to Success

Collaboration with IHI – essential at the start and guidance throughout process Dedicated Heart Failure Program Coordinators Senior Leadership and Champions Learn from Failures Start before ready Cohesive, committed Multidisciplinary Heart Failure Team Palliative Care Team Collaboration Outpatient program & Community Partners- Cross Continuum Team 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

The Power of the Patient Story

Photo used with permission and signed consent by the patient.