From Knowledge to Practice Translation

A Multidisciplinary Intervention to Reduce 30 day Heart Failure

Readmissions

Context

• Rehospitalization ≤30 days marker of poor quality – Reduction of unnecessary rehospitalization is a way to

improve quality and decrease cost

• Limited data re: patterns of rehospitalization in U.S.

• Jencks et al. (2009) NEJM– What is the frequency of rehospitalization of

Medicare patients within 30 days after discharge?– How long does the risk of rehospitalization persist?– What is the frequency of outpatient followup after

hospitalization?

Jencks S et al. (2009) NEJM 360(14): 1418-1428

30 day rehospitalization

• 19.6% of all Medicare patients rehospitalized within 30 days of discharge– Medical diagnoses – 21.1%• Heart failure – 26.9%

– Surgical diagnoses – 15.6%• No record of outpatient follow-up visit for 50.1%

of patients rehospitalized within 30 days after discharge

• No outpatient follow-up visit for 52% of those rehospitalized within 30 days after discharge for heart failure

Jencks S et al. (2009) NEJM 360(14): 1418-1428

Heart failure readmission and HLOS relationship

Winslow R, Wall Street Journal, June 2, 2010

The Allen Hospital Project

Graham et al., 2006

28.3%

The population

Strategy

Teambuilding

Preparatory work

Intervention components

Practice change

Effect on 30 day readmission

Would improvement have happened anyway?

Core measure improvement

Lessons Learned

But the story doesn’t end here…..

Ongoing Monitoring 2012

• Rise in readmission rates • Characteristics of those

readmitted analyzed• Chronic kidney disease• Dementia• Respiratory diseases• Poor social support• Medication discrepancies

• Review of meds by pharmacist prior to discharge

• Need for palliative care team