Congestive heart failure (CHF) is a chronic cardiovascular disease with a broad spectrum of acuity. Acute exacerbations are characterized by rapid onset of signs and symptoms secondary to the inability of the heart to effectively pump enough blood to meet the patient’s oxygen demands. CHF is a highly prevalent condition commonly associated with significant morbidity and poor quality of life. It is a strong predictor of heart failure hospitalization and all-cause death in patients with poor health-related quality of life.(1,2) The prevalence of heart failure in the United States was 6.7 million between 2017 and 2020 in patients older than 20 years of age.(3) Prior studies have shown that up to 18.6% of patients hospitalized for acute heart failure exacerbation are readmitted to the hospital within 30 days of hospital discharge, and more than half die within five years of diagnosis.(1,4) From 2010 to 2017, the rates of heart failure–specific 30- and 90-day readmissions have increased, despite the introduction of hospital readmission reduction programs.(4) The need to improve these statistics is undeniable.
Unplanned hospital readmissions are very expensive.(5) Hospitals with readmission rates higher than expected face financial penalties from CMS. Social determinants of health are prevalent in communities served by our institution, Samaritan Medical Center, and play a causal role in many preventable hospital readmissions. These factors include low socioeconomic status, social isolation, inadequate health literacy, substance abuse, and poor mental health. In response to this issue, Samaritan Medical Center implemented a Congestive Heart Failure Readmission Reduction Project in 2022. The goal was to decrease hospital length of stay and reduce readmission rates for patients with a primary diagnosis of CHF exacerbation. This was accomplished using a multicomponent approach involving a multidisciplinary team of physicians, nurses, case managers, home health coordinators, and administrative support.
Methods
In 2021, 54 patients were readmitted to Samaritan Medical Center with a primary diagnosis of CHF. We estimate the cost of these readmissions as $849,528. In response, we designed a readmission reduction project with the goal of decreasing readmissions for patients with a primary diagnosis of CHF. Multicomponent interventions are effective at decreasing hospital readmission rates.(6) A multidisciplinary team composed of physicians, nurses, case managers, home health coordinators, and community-based organizations developed a transition of care plan. The plan included clear communication, patient education, discharge planning, close outpatient follow-up, and remote patient monitoring. Funding was provided by Samaritan Medical Center with grant support from Excellus BlueCross BlueShield-Utica Region and the North Country Initiatives.
Patients with two or more admissions with a primary diagnosis of CHF in the last 12 months were identified on Day 1 to be included in the field report (Figure 1). Informed consent was obtained from each patient prior to enrollment. Each patient received CHF educational materials and was assigned goals and responsibilities to aid them in understanding their diagnosis. Physicians and charge nurses learned about new enrollees during daily multidisciplinary rounds. A designated Samaritan Home Health (SHH) employee assumed the role of patient care coordinator. Their main function was to facilitate transitions of care upon discharge through better relationships with patients, family members, nursing staff, and attending physicians.
Figure 1. Key components of patient implementation in the Congestive Heart Failure Hospital Readmission protocol. ED, emergency department; PCP, primary care provider.
Prior to discharge, patients were expected to understand proper monitoring of weight, intake and output, vital signs, fluid restriction, medication use, and side effects. Each patient met with a dietitian and was educated on proper dietary habits. On the day of discharge, patients were given a discharge plan, CHF educational materials, and a CHF Zones for Management form. Patients were scheduled for a hospital follow-up appointment with their PCP within seven days of discharge. A cardiology follow-up appointment was scheduled if the discharging physician deemed it clinically necessary.
Patients were discharged with a personalized order set, which included a 3- or 5-day prescription order for metolazone, 2.5 or 5.0 mg, and home diuretics determined by the discharging physician. The prescription acted as an extra “pill in the pocket” supervised strategy by the visiting home nurse. The pill-in-the-pocket model has been used previously for atrial fibrillation. For this project, we developed a pill-in-the-pocket strategy where patients are discharged home with an additional medication such as metolazone or furosemide.(7)
Continuity of Care upon Discharge
Once at home, patients were visited by a SHH nurse. The nurse’s initial assessment included a full set of vital signs. They reviewed fluid and sodium restrictions and completed a medication reconciliation exercise. Patients were educated using the teach-back method. A SHH on-call nurse was available 24 hours a day, 7 days a week to answer patients’ calls and direct care according to their individualized care plan.
As noted in previous studies, disease management programs aimed at reducing heart failure readmissions should be tailored to individual patient needs. Structured telephone support was incorporated into the readmission reduction protocol, because Samaritan Medical Center serves a large geographic area; this allowed patients to receive continued care despite geographic distance.(8) The patient care coordinator visited each patient in their home within 24 hours of discharge for further education and delivery of remote monitoring equipment (i.e., Bluetooth-enabled scale, pulse oximeter, blood pressure cuff, and tablet with Internet access). Patients were educated on how to properly measure vital signs and use the tablet. They entered daily vital signs and filled out a short symptomatology questionnaire onto a medical app on their tablet at the same time each day. Results could be seen by the care team once they were uploaded to the app.
Any patient with abnormal vital signs or positive symptomatology was contacted by the on-call nurse and visited within two hours. If a patient gained 2 lbs in 24 hours or 5 lbs in one week, the protocol was initiated. Furthermore, lab work was obtained (i.e., basic metabolic panel, magnesium), and patients were assessed for fluid overload and symptomatology (Figure 2).
Figure 2. Criteria for protocol initiation. [1] Evidence of volume overload: new tachycardia, new dyspnea, orthopnea, tachypnea, decreased oxygen saturation, new or increased rales, new or increased peripheral edema, early satiety, abdominal bloating. [2] Unstable vital signs: respiratory rate > 30 breaths/min/respiratory distress, systolic blood pressure <90 or >180 mm Hg, resting heart rate <50 or >100 beats per minute, or significant change from patient’s baseline mentation. [3] Supervised ED visit. Home health nurse will call the ED provider and notify them that this patient is participating in the CHF readmission program. Patient will be evaluated in the ED by ED physician and it will be determined whether he or she needs inpatient management or can be sent home with changes in medications. BMP, basic metabolic panel; ED, emergency department.
Step 1: If a patient appeared euvolemic or fluid overloaded with stable vital signs and no symptomatology, they were assessed for treatable causes of weight gain and educated as needed. An increase in diuretic was initiated (Step A) and vitals were rechecked in 6–24 hours.
Step 2: If patient’s weight returned to baseline and symptoms resolved, labs were drawn, and previous medication doses were resumed. If the weight was not at baseline or increased and vitals remained stable, Step B was initiated.
Step 3: If weight returned to baseline with resolution of symptoms, labs were drawn and previous medication doses were resumed. If the patient’s weight was not at baseline or increased and vitals remained stable, Step C was initiated (IV administration of diuretics, STAT lab work, and rechecking of vitals in 6–24 hours).
Step 4: STAT lab results were checked and patient weight was assessed. If weight was back to baseline and symptoms had resolved, previous medication doses were resumed and ongoing monitoring was continued. If weight was not back to baseline or increased, Step D was initiated. For Steps 2 and 3, if patients returned to their baseline weight, they were advised to return to the start of Step 1 (Figure 3).
Figure 3. Discharge protocol for patients enrolled in CHF readmission reduction project to assess for CHF exacerbation and treat accordingly. [1] Maximum daily doses are furosemide, 320 mg; bumetanide, 10 mg; torsemide, 200 mg. CHF, congestive heart failure; IV, intravenous; BID, twice daily; PCP, primary care provider.
Once the protocol was initiated, patients were visited again within 24 hours by the on-call nurse. If the nurse determined a patient needed immediate assessment by a provider, they coordinated an expedited appointment with the PCP. Once available, lab results were reviewed by the patient’s primary care provider. During each step in the protocol, if the patient exhibited volume overload with unstable vital signs, chest pain, new dysrhythmias, or coexisting illness, the PCP was notified.
To prevent unnecessary hospitalizations and reduce hospital visits, supervised emergency department visits were implemented. If a patient exhibited concerning findings, the emergency department staff were made aware that the patient was enrolled in the readmission reduction program, and every effort was made to discharge the patient under SHH supervision. Once discharged home, the SHH on-call nurse would assess the patient within 24 hours. Of note, two patients who were sent to the emergency department for a supervised visit avoided being admitted due to this program. The two patients were able to be managed appropriately at home with guidance from their PCP without any readmission.
Each patient also was visited by a social worker upon discharge to aid in creating a meaningful relationship between the patient and their healthcare team as well as to assess social determinants of health to help prevent further hospital readmissions. If the social worker determined the patient would benefit from their help, they continued to follow up with the patient routinely.
Results
Our field report was conducted from January 1, 2021, to June 30, 2023, at one center in New York state. The baseline observed to expected (O/E) CHF readmission rate from January 1, 2021, to December 31, 2021, was 1.13 (Table 1). The CHF Readmission Reduction Project was fully implemented on February 28, 2022. The O/E readmission rate for CHF from January 1, 2022, to December 31, 2022, dropped to 0.96 (see Table 1). The O/E readmission rate from January 1, 2023, to June 30, 2023, was further reduced to 0.83 (see Table 1). The O/E readmission rates comparing CHF versus all cause are noted in Figure 4.
Figure 4. Congestive heart failure hospital readmissions. Observed/expected ratio of CHF versus all cause prior to and after implementation of quality improvement protocol. CHF, congestive heart failure; O/E, observed/expected.
Conclusion
Our investigation found a decrease in CHF hospital readmissions after implementation of a readmission reduction protocol in a rural community hospital. The importance of this reduction is not only linked to hospital wide financial savings—this reduction works toward a reduction in human suffering.
Stress during hospitalization is not limited to feelings of anxiety and depression.(9) Patients also report feelings of suffering from their failing health and worry about how their illness affects their loved ones.(10) Evidence-based management of heart failure requires a comprehensive approach, including hospitalists, cardiologists, and primary care providers. A structured transition of care plan with remote patient monitoring, and a well-defined set of criteria for the initiation of rescue medications has the potential for decreasing avoidable hospital readmissions. There are approximately 1800 community hospitals in the United States similar in size to Samaritan Medical Center.(11) This protocol has reduced preventable hospital readmissions in the community served by Samaritan Medical Center. We are hopeful that, if replicated in the right settings, it has the potential to do the same in different communities.
Limitations
The current field report has several limitations. First, the study was not randomized and did not include a control group for comparison. All patients were aware of their enrollment in the CHF readmission reduction projection, a fact that could lend to patient bias. The lack of a control group for comparison limits our ability to assess for reduction in readmissions based solely on readmission protocol introduction. Second, the sample size of participants is small, which reduces the statistical power of the report. Third, the study does not include comparison data of admission rates in surrounding regional hospitals. Fourth, the field report has broad inclusion criteria and limited exclusion criteria. The inclusion criteria do not include specified demographics, and we did not take into account the functional New York Heart Association (NYHA) class status or ejection fraction in the patient population. We only took into account the diagnosis of CHF, which was a clinical diagnosis at the time of admission. If we were to create additional exclusion criteria the power of the field report would decrease.
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