Cardiovascular disease, CVD, is the leading cause of death in the United States. Cardiovascular disease includes all diseases of the heart and blood vessels, including ischemic heart disease, stroke, congestive heart failure, hypertension, and atherosclerosis. Amongst the most common of these diseases is congestive heart failure (Georgia Department of Public Health). With a upward drift of congestive heart failure (CHF) rates, CMS, the Centers for Medicare and Medicaid Services, in compliance with the Patient Protection and Healthcare Reform Act of 2010, introduced a pay for performance or value-based purchasing method that penalizes hospitals with higher readmission rates (Centers for Medicare and Medicaid Services).
For patients over the age of 65 that require hospitalization, CHF is the leading reason for admissions (NHLBI, 2011). In 2001, there were “over 500,000 hospital admissions primarily for CHF in women and over 400,000 in men”, up from 200,000 in 1970 (Young, 2004). With the forty percent of readmissions being voidable, and one in four Medicare CHF patients being readmitted within a month, the goals of Healthy People 2020 includes a reduction in hospitalization of older adults with heart failure as the principal diagnosis (Healthy People 2020 Heart Disease & Stroke, 2011). James Young, in the article The Global Epidemiology of Heart Failure, stated that in 2001, there were over 900,000 hospitalizations primarily for CHF, a tremendous spike in numbers from 200,000 reported in 1970 (2004).
African-American population has higher prevalence of heart failure than White Americans, especially at a younger age (Sharma, Colvin-Adams & Yancy, 2014). Comorbidities such as diabetes, hypertension, kidney disease and obesity are common in the African-American population in the city of Atlanta (CDC, 2010), and all these factors are predisposition to heart failure (Sharma et al., 2014). Socioeconomic status also plays a role in the predisposition of heart failure development.
When assessing and/or treating acute exacerbation or chronic heart failure patients, in and out of hospitals, it takes an organized interdisciplinary team to manage the care. Recognizing the patients condition and providing diagnosis appropriate care, is vital in the management of heart failure. Interviews were conducted with emergency room nurses as well as intensive and progressive care units, also physicians, case management and social workers, and nursing administration personnel to gather information of the amount of patients, within the target population, hospitalized for a primary diagnosis of heart failure and the 30-day readmission rates and outpatient compliance to treatment and disease management.
Wellstar Atlanta Medical Center in Atlanta, GA for example, has a heart failure education program for all hospitalized patients. Patients received a individualized visit from the heart failure educator nurse, who reviews treatments and health promotions with each patient within 24 hours of admission. Also, within the topics that are discussed are complications of heart failure and symptoms to monitor, diet plans, exercises, medication regimen, weight monitoring, diagnostic testing and the importance of outpatient follow up.
Many local hospitals are also implementing follow up appointment scheduling within 1 to 2 weeks, for the hospitalized patient to help minimize the readmission rates. Some hospitals have community clinics, such as the Sheffield Health Clinic at Wellstar Atlanta Medical Center, to help the noninsured and low-income population to have a physician follow up visit at little to no cost. Wellstar Hospitals have also implemented a Heart Failure Hotline, for patients and family members to call 24 hours, 7 days weekly, with questions regarding symptoms and medication regimen.
What is not Being Addressed?
When it comes to the readmission rates, and CMS compliance, there are a few things I have noticed some clinical settings, when educating and interviewing heart failure patients, family members, health care personnel, and physicians, is that there have been some things that were not being addressed or implemented within heath care systems to improve the process. This is the fact that the United States is a big cultural melting pot for tourists and residents from other countries. Language lines when educating these patients are not always being used, and education leaflets were not made available in other languages, and these non-English speaking patients are amongst those being readmitted for heart failure treatments within 30 days.
Also not being addressed in interviews I conducted, is the question “does those heart failure patients, whom appointments were made for, make it to their outpatient follow up visits?” There is no guarantee that the patient will in fact follow up in community clinics or with their primary physicians and specialists.
In compliance with Healthy People 2020 (healthypeople.gov), to “Improve cardiovascular health and quality of life through prevention, detection, and treatment,” and CMS under the Patient Protection and Healthcare Reform Act of 2010, achieving the goal would depend on individual healthcare teams. Utilizing the interdisciplinary team made available in hospitals and outpatient clinics to ensure patients understand the disease process, medication regimen, and outpatient resources along with ensuring outpatient physician follow-up visits, will assist to improve the number of primary heart failure hospitalizations.
The implementation of an interdisciplinary team approach to individualized patient care, and use of evidence-based practices will enhance the treatment and management of heart failure. Using bilingual educators, or making language lines promptly available to nurses and other healthcare team members will encourage participation of non English speaking patients. Also, encouraging a dietician consultation to better orient patients on food and fluid restrictions will assist with in-home dietary management. Case manager and social workers can collaborate with community providers to provide outpatient assistance to lower income heart failure patients, to transport to appointments, as well as in-home visits. Nursing units can implement discharge phone calls to ensure patients are following their suggested treatment plans, and are able to fill prescriptions on timely manners, as well as take their daily medications as instructed.
The plan to minimize the 30-day readmission rate has to be taken not as a business move by hospitals hoping not to be penalized by CMS, but to ensure the community they serve has the proper care necessary to prevent readmissions. Starting with nursing units and health care team members, implementing quick and cost-effective steps will direct the patients to become aware of their disease process, treatment and possible complications, as well as provide the patients with means necessary to be able to transition from inpatient to outpatient and manage their conditions at home.
Nursing Action Plan
In accordance to Healthy People 2020, the goal to “improve cardiovascular health and quality of life through prevention, detection, and treatment of risk factors” (healthypeople.gov), can be achieved by orienting health care workers and the interdisciplinary team to properly educate patients on treatments and disease management. As well as to encourage family members to become involved in the care, and also have cardiac screenings for predisposition and risk factors, allowing for early detection and prevention.
To improve the hospitalization length of stay, and minimize readmission rates in compliance with the Patient Protection and Healthcare Reform Act of 2010, the health care team must have a plan in place to monitor the patients after discharge. To ensure follow-up appointments are being met and patients are able to care for self at home. Nurse educators and staff nursing staff must ensure patient’s knowledge of disease process and medication regimen.
Population-Focused Specific Nursing Interventions
Programs to manage chronic diseases such as heart failure and COPD can reduce the readmission rate by 40% (Krumholz et al., 2002). In the randomized study by Yale School of Medicine, published by the Journal of the American College of Cardiology, providing formal patient-centered inpatient education of the disease and management, followed by several teaching sessions while hospitalized. Once the patient was discharged, home visits were set up with educational sessions to bridge any knowledge gap a patient may have had, followed by biweekly phone calls for eight weeks, then monthly for one year. This study showed a 39% reduction in primary heart failure diagnosis readmission within 1 year (Krumholz et al., 2002).
To optimize the patient’s quality of life, and incentivize disease prevention and health promotions, Healthy People 2020 has teamed up with many private sector partners to develop the Million Hearts campaign. The initiative is to prevent 1 million heart attacks over the next 5 years (healthypeople.gov). Cardiovascular disease prevention functions in two spectrums, the clinic and the community. The clinic realm of the Million Hearts campaign will work to improve the medical management of the disease, whereas the community will take initiative to encourage disease prevention, such as exercise, smoking cessation, and dietary control to meet the Healthy People 2020 target goal (healthypeople.gov).
Nurses are in a position that can affect both the clinical as well as the community setting. Through disease management and patient care for hospitalized patients, nurses are the frontline members to educate and encourage the patients to manage the disease and prevent complication. Through repetition, educational material must be given to the patients, as well as give them time to express concerns and barriers to care. With the help of case managers and social workers nurses may also affect tremendously the community realm of Million Hearts campaign, assisting the patients with instructions on self-care, and importance of follow-up physician visits. Nurses may also implement discharge phone calls to ensure patients are complying with suggested regimen and are able to attend the scheduled follow up appointments.
IT TAKES A VILLAGE!
On April 25th, 2017, Atlanta kicked off a global pilot program for heart failure research, which is intended to improve patient outcome and decrease healthcare costs. The World Economic Forum chose Atlanta for the site of the 3-year study, where twenty payer, provider, supplier and government associations in Georgia are gathering to tackle the cause. Atlanta’s Mayor Kasim Reed has announced his support for the study announcing in a town hall meeting that the intent is to become national leaders in the survival rate in heart failure patients in the United States, while working to improve the quality of life and reducing the care cost to the local population. Mayor Reed also stated that the plan is to become a model community for value-based health care.
Companies such as Novartis AG, Takedo Pharmaceuticals, Kaiser Permanente, Qualcomm along with Blue Cross Blue Shield of Georgia, Grady Health System, Emory Healthcare and other community health systems have joined together to invest on the three-year study. Atlanta was chosen as the pilot city due to its central location and prevalence of heart disease in the southeast United States. A study of this magnitude is of great importance for the citizens of Atlanta, especially those dealing with heart failure, Georgia’s heart failure one-year mortality rate is 30%.
When implementing a nursing action plan, both a short-term and long-term goals should be set. Implementing a nurse-patient initiative to improve patient outcome, minimize readmissions and ensure outpatient follow-up is the short-term goal. The nursing units and its interdisciplinary team members must initiate the patient-centered care model, with daily educational sessions while hospitalized, as well as continuation of outpatient follow-up appointment scheduling, and medication regimen teaching.
Once patient is discharged home, nurses will implement discharge phone calls biweekly for the first 8 weeks and monthly for one year following hospital discharge. Also, the case managers and social workers must work with local resources to ensure patients are being compliant with the care at home. Home visits by nurses to assess and educate patients on medication and dietary regimen, should be arranged by case managers once patient leaves the hospital. If necessary, patients should be assisted with arranging transportation to primary care physicians and specialists.
The long-term goal will be to have the entire community on the same page. Reducing the rate of readmission and improving the one-year mortality rate. In three years, once the Atlanta pilot study is complete, with proven records that implementation of a patient-centered program measuring outcomes and costs, focusing on population segments and customizing segment-specific interventions improves the overall patient health and outcomes, as well as lowering the healthcare costs, the program can be taken global.
Implementing a comprehensive heart failure and other chronic disease programs such as this, will require the help of both hospital nurses and care team, as well as community nurses and healthcare agencies. To assess and evaluate the success of the action plan, different tools and disciplines will be required. To evaluate the first objective which regards the health promotion, prevention and disease management, patients and family members will be surveyed and examined on their knowledge of their disease process and management, along with their compliance strategies. Patients will need to be followed for the entire year and progress or regression must be documented. An increase in patient surveillance will decrease acute exacerbation of disease and assist family members with the prevention of heart failure development, thus providing proof of a successful program.
The amount of patients that will in turn avoid readmission to hospitals due to heart failure will be tracked. Information gathered will be passed unto the state's Health Departments that will in turn track the outcome of the program, thus reducing the overall cost of care for individuals and the state.
Cardiovascular disease is the number one cause of death in the United States. It is undoubtedly important to decrease the incidence of cardiovascular disease diagnosis, and to improve the quality of life of those currently dealing with them in our community. To achieve this goal, in compliance with Healthy People 2020, it will take a large-scale movement that can start at the patient’s bedside. Nurses can implement changes in the care of their heart failure patients by providing repetitious educational material and lectures on how to achieve optimal management of their disease. Along with other healthcare team members, nurses can also ensure their patients receive adequate outpatient assistance to minimize the readmission rates, as well as increase the survival rate.
The Dude Nurse
Klaus Campos, BSN-RN