Improving Outcomes for Unfunded Cardiac Patients: A Team Approach

Joe Garcia DNP, RN

Importance Of Quality Improvement

• Under Medicare's Inpatient Prospective Payment System (IPPS), as included in the Affordable Care Act (ACA), there will be adjustments to payments made for excessive readmissions in acute care hospitals during fiscal years beginning on or after October 1, 2012.

• A readmission is defined as: being admitted at the same or different hospital within a period (generally 30 days) for certain applicable conditions.

Heidenreich et al,(2011)

Conditions/Impact

• Myocardial Infarction (MI), Congested Heart failure (CHF), Pneumonia (PN).

• Between 2010-30, the cost of medical care for heart disease will rise from $273 billion to $818 billion.

Heidenreich et al,(2011)

Importance

• Largest public hospital located directly on the U.S./ Mexico border.

• Serves the third poorest county in the nation.• Per-capita income in the hospital’s primary

service area is just $17,618.00.• Majority (80%) of El Paso's population is Hispanic

and many are fluent only in Spanish. • 33.2% of the 800,647 residents are uninsured. Texas Comptroller(2012)

Aim/ Goal

• Implement a low cost high impact discharge protocol/ model for the uninsured/underinsured patients that require essential medications upon discharge.

• Improve patient care quality and minimize readmissions and their costs; among this population on a continuous basis.

Background

• Ischemic cardiovascular disease (CVD) is the most common preventable cause of death in the U.S.– Creates major health and cost issues with

regard to hospitalizations and readmissions. – Readmissions stem from non-compliance

with medication therapy.

Background

• Following hospitalization for CVD, one-fifth of Medicare patients are readmitted within 30 days. ( Berenson et al, 2012).

• Readmissions are costly and their impact – financial and otherwise – is increased by the fact that readmitted patients have a higher mortality rate ( Kavey, 2003).

Background

• Readmissions and their ever attendant, ever increasing burdens are often preventable ( Yost et al, 2010)

• Major factor in readmissions is that patients delay, stop, or never fill their prescriptions post discharge ( Yost et al, 2010)

Significance Of The Problem

• Each year there’s six million hospitalizations due to heart disease ( AHA, 2007).

• Ten million cases annually of disability for Americans age 65 years and older (AHA, 2007).

• Approximately 1.2 million Americans suffer heart attacks each year (CDC,2009).

• Of that number, 700,000 are first-time attacks and another 500,000 are experiencing recurring attacks (CDC, 2009).

Case Study

• On the 14th week of the study, Cath team performed an urgent percutaneous coronary intervention (PCI) on 38 y/o patient with previous history of myocardial infarction.

• Primary admission was September 12, 2012. • Information obtained from the electronic

health record (EHR) proved additional injury to the myocardium.

Case Study

• The EHR and images taken during the procedure revealed that all three major vessels had in-stent thrombosis.

• Documentation in the EHR stated the patient had self-reported non-compliance with previously prescribed medications.

Review Of Literature

• “The most common etiology of... readmissions due to complications of PCI was in-stent thrombosis” (Yost et al, 2010).

• In-stent thrombosis is the leading adverse event associated with early discontinuation of essential medication therapy (Yost et al, 2010).

Review Of Literature

• One study found 1 in 6 patients delay filling their prescriptions after hospital discharge after having coronary intervention (Ho et al, 2010)

• Premature discontinuation of medication therapy is the single greatest predictor of complications post intervention and has a 25 to 40% mortality rate (Ho et al, 2010 ).

Quality Assurance Framework( Avedis Donabedian)

• Provides a tool for measuring quality of care.• A multidisciplinary approach to process

change.• Powerful tool for change and measuring

improvement.

Ethical Considerations

• Study inclusion criteria required that all project participants be older than 18 years with proper documentation of medication dispensed at discharge.

• Prior to implementation, the project was assessed by the institution’s IRB officer and determined to be a quality improvement project, which did not require IRB review.

Method

• Plan, Do, Study, and Act (PDSA) cycles are a means of doing effective, consistent quality improvement over multiple discrete phases and iterations (IHI, 2011). 10

• This quality improvement protocol had three distinct phases:

1. Building the best practice tool using a pilot;2. Implementing the tool based on pilot data; and3. Monitoring and utilizing the protocol to actually

increase compliance.

Important Factors Of Project

• Partner with pharmaceutical companies to provide a free 30-day discharge supply of medications to uninsured and underinsured patients that have received cardiac treatment.

• Reduce or eliminate medication associated readmissions.

• Increase the transition and coordination of care provided.

Implementation• A prospective study was conducted

implementing the proposed medication protocol that involved the physician, nurse, pharmaceutical company, social worker, and pharmacists.

• The study was conducted for an eight-week period while observing for the outcome of interest. Findings were compared to those obtained in the retrospective study.

• All data collected was obtained from the EHR along with pharmacy dispensing data.

Best Practice Tool

Best Practice Tool

Medications To Date

Basic Steps Of The Discharge Medication Protocol

Step 1. Rational

Start discharge process on admission. Helps identify the financial and pharmaceutical needs of the patient.

Assist the uninsured to enroll into Medicare/ Medicaid.

Step 2.

Interdisciplinary Communication Completing and faxing computerized form within 24 hours of admission.

On approval, pharmacy communicates to the physician and case manager the need for prescriptions.

Step 3.

Medications Pharmacy delivers 30 day supply of medications on discharge day.

Simplify management plan, acquisition of medications, storage, and proper administration.

Basic Duties Of Discharge TeamParticipant Role

Patient financial representative Conducts/completes computerized pharmaceutical form and delivers to pharmacy.

Pharmacists Conducts medication reconciliation, looks for gaps in medication that may have lead to hospitalization, and authorizes the dispensing of essential medications.

Case manager Notifies physician of patient pharmaceutical status and request prescriptions.

Social worker Assists patient access community services such as transportation to appointments, coordinates with behavioral specialists to provide support to patients with depression, particularly post Myocardial infarction.

Nurse Sets discharge planning in motion. Role includes hospital discharge planning to include DC teaching.

Project Design

• Data was collected from two retrospective chart reviews:– May 1, 2011 through July 30, 2011 – May 1, 2012 through July 30, 2012

(Retrospective studies use existing data that has been recorded for reasons other than

research)

Findings Retrospective Review 2011

May 1, 2011 through July 30, 2011

• Cath team performed a total of 40 Urgent/ Emergent PCI’s.

• One patient returned to UMC within a 30 days.• Charity care • Length of Stay (LOS) (3) days• Costs associated with readmission $52,376.14

Findings Review 2012

May 1, 2012 through July 30, 2012

• Cath team performed 26 Urgent/ Emergent PCI’s.• Five patients returned to UMC within a 30 days.• One Medicare , four self-pay • Average Length of Stay (LOS) 5 days.• Total charges for second readmission $298,660.28

Financial Impact Combined2011 and 2012 = $351,036.42

Or $58,506.07/ patient

Prospective Study Findings

November 1, 2012 through January 31, 2013

• Cath team performed 38 Urgent/Emergent PCI’s.• All discharges had the 30-day supply of essential

medications.• No readmissions• Continued through February• No readmissions

Secondary Findings

• 98% of the population qualified for the free 30-day supply of medications.

• HCAHPS scores rose from 87% to 99%.

• Three enrollments

Barriers To Implementation

• Resistance to change

• Various interests

• EHR Challenges

• Education

Recommendations

• Given the association between discontinuation of medications and 30-day readmissions, additional strategies are needed to identify and understand the discharge process.

• Quality improvement initiatives must be undertaken to better educate patients about their diagnosis and medications.

Recommendations• Evidence-based medication protocols are

necessary for patients who have been discharged to ensure initial filling of prescriptions and prevent the delay or stoppage medications.

• The hospital team must identify and determine the best approach to increase adherence.

• For patients who cannot afford the essential therapy due to demographic, educational, economic, and social-cultural factors, alternative medication regimens need exploration.

Summary• Adherence to medication is one of the most

interesting and difficult to understand behaviors demonstrated by patients.

• Adherence is affected by demographic, educational, economic, and social-cultural factors.

• Non-adherence to a therapeutic regimen has shown to result in negative outcomes for patients and may be more complex in populations with multiple morbidities that require multiple drug therapy.

Summary

• This project focused on a protocol to provide unfunded CVD patients necessary medications upon discharge.

• The use of the protocol clearly demonstrated the value of providing essential medications to unfunded patients following PCI.

• During the study period, there were no readmissions within the 30-days following discharge.

Sustainability

• Teams will have to have standardized methods of monitoring these outcomes.

• Periodically present findings to staff to show that goals are being met, or to discern reasons why they are not being met.

• Make the necessary changes to protocols that would address these issues.

• Collect monthly statistics on patients that are both admitted and readmitted for CVD care.

Result Distribution

• Abstract submitted for poster presentation to the Mano Y Corazon 2013 Bi-national Conference of Multicultural Health Care Solutions. September 2013, El Paso, Texas.

• Manuscript submitted to the Journal of Nursing Care Quality on April 11, 2013.

Coming Quality Improvement

On March 6, 2013 submitted for grant funding.

•Advocate for the poor and disparate population of El Paso. •Engage the El Paso community to improve CVD awareness through screening, culturally appropriate bi-lingual education, promote change in dietary habits, and increase awareness of warning signs of heart attack and importance of calling 911.

Coming Quality Improvement

• Million Hearts campaign: a National initiative that was launched by the Department of Health and Human Services in September 2011 to prevent 1 million heart attacks and strokes by 2017.

Case Study• Balloon pump for 6-days (CCU bed) $10,800• 15-20% ejection fraction verified via MUGA

$871.00• Back to cath-lab. Right coronary artery opened

$23,162.23• By-pass for remaining two arteries $76,421.40• Pharmacy $8464.25• Supplies $9621.00• Total costs for readmission $129,339.88

Could this have been prevented ?

References• American Heart Association. (2007). Cardiovascular Disease Statistics. Retrieved from http://www.heart.org/

• Berenson, R.A., Paulus, R.A., & Kalman, N.S. (2012). Medicare's readmissions-Reduction program. New England Journal of Medicine, 366, 134-136.

• Centers for Disease Control and Prevention. 2009 Know the Signs and Symptoms of a Heart Attack. Retrieved July, 01 2012 from www.cdc.gov/dhdsp/data_statistics/fact_sheets/.../fs_heartattack.pdf

• Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., Finkelstein, E. A., Hong, Y., Johnston S.C., Amit, K., Lloyd-Jones, D.,Nelso, S.A., Graham, N., Orenstein, D.,Wilso,W.F.,& Woo, J. (2011). Forecasting the future of cardiovascular disease in the United States: A policy statement from the american heart association. Circulation, 123, 933-944.

• Ho, M. P., Thomas, S. T., Thomas, M. M., Powers, D. J., Nikki, C. M., Jackevius, C. E., Go, A. S., & Margolis, K. L., DeFor, T.A. (2010). Delays in filling clopidogrel prescription after discharge and outcomes after drug-eluting stent implantation. Circulation, 3, 261-266.

• Institute for Healthcare Improvement. (2009). Care Coordination Guidelines. Retrieved from http://www.ihi.org/

• Institute of Medicine. (2000). Care Equity Report. Retrieved from http://www.iom.org/

• Kavey, W. E. R., Daniels, S. R., Lauer, R., Atkins, D. L., Hayman, L., & Taubert, K. (2003).American heart disease guidelines for primary prevention of athersclerotic cardiovascular disease beginning in childhood. Circulation, 107, 1562-1566.

• Khot, N. U., Johnson, M. L., Geddes, J. B., Ramsey, C. A., & Khot, M. B. (2008). Financial impact of reducing door-to-balloon time in st-elevation myocardial infarction: A single hospital experience. BMC Cardiovascular Disorders, 9, 32.

• Neushausen, M. B. (2004). Avenis Donabedian: father of quality assurance and poet. Quality Safe Healthcare, 13(6), 472-473.