Fixing Matters of the Heart

Heart failure, with its health care services, medications, and effects on productivity, costs the nation more than $34 billion each year. According to the American College of Cardiology (ACC), heart failure is the leading cause of hospital readmissions in the United States. After recognizing that heart failure readmission rates in its area were noticeably higher than the national average, the Aligning Forces for Quality (AF4Q) initiative in Detroit, led by the Greater Detroit Area Health Council (GDAHC), launched efforts to improve early follow-up processes for heart failure patients and helped to reduce readmissions.

GDAHC partnered with the Michigan Chapter of the ACC and the Michigan Peer Review Organization to form the Southeast Michigan “See You in 7” Hospital Collaborative. Early results indicated that the 11 hospitals that participated in the collaborative reduced readmissions by 10 percent.

“I have been involved in other readmissions projects; this was more of a one-on-one, interactive approach. ‘See You in 7' definitely had solutions that we could really sit down and work with,” said Jacqueline Jones, MSN, manager of cardiovascular services at Crittenton Hospital Medical Center. “We had a problem getting information to primary care practices (PCPs). That’s a big thing, care transitions. How do PCPs know what is happening to the patient in the hospital?  We made a goal for patients to receive PCP appointments for follow-up within seven days post discharge prior to leaving the hospital.  In addition, we ensured the PCP had appropriate patient clinical information at the first post discharge visit to further ensure seamless care transitions.”

Participating hospitals had access to expert coaching, tools, and strategies and participated in monthly calls or webinars to share best practices, lessons learned, and tactics deployed. The program focused on the following success measures that evaluated progress from the ACC’s “See You in 7” toolkit:

1. Identifying heart failure patients prior to discharge
2. Scheduling and documenting a follow-up visit with a cardiologist or primary care practitioner that takes place within 7 days after discharge
3. Providing the patient with documentation of the scheduled appointment
4. Identifying and addressing barriers to keeping the appointment
5. Working to ensure that the patient arrives at the appointment within 7 days of discharge
6. Making the discharge summary available to the follow-up health care provider

“With the program we hoped to improve patient outcomes and align with the readmission reduction goals of national initiatives, such as the National Partnership for Patients,” said Kate Kohn-Parrot, CEO at GDAHC.

Examples of interventions that hospitals implemented include a follow-up communication plan for heart failure patients, patient transportation guides, automated reporting of electronic medical records, and streamlining the process of identifying heart failure patients. Hospitals also partnered with local organizations to strengthen efforts. For example, Oakland University’s nursing program expanded its community rotation options to include assistance with “See You in 7.” Nursing students visited patients at home to do a full check-up, reinforce education, and answer any questions. 

“GDAHC plans to continue to explore and improve transitions of care,” said Lisa Mason, vice president of GDAHC and Project Director of the Detroit AF4Q Alliance. “To sustain the objectives of ‘See You in 7’ requires a culture change and more focus on patient needs and acknowledgement of patient vulnerability at discharge. “