# Presentation: 579022

## VA Heart Failure Network

- 9/17/2007

**Notes:**
VA Heart Failure Network

9/17/2007

## Improving Early Follow-up Following Heart Failure Hospitalization

- Paul Heidenreich MD, MS
- Barry Massie MD
- Anju Sahay PhD
- Robert Jesse MD, PhD

**Notes:**
Improving Early Follow-up Following Heart Failure Hospitalization

Paul Heidenreich MD, MS
Barry Massie MD
Anju Sahay PhD
Robert Jesse MD, PhD

## Questions

- Improving Early Follow-up Post Discharge
- Is this worth addressing?
- What can we do with current resources?

**Notes:**
Questions

Improving Early Follow-up Post Discharge
Is this worth addressing?
What can we do with current resources?

## Background

- How is the US Medicare doing?
- How is the VA doing?
- Institute for Healthcare Improvement (IHI) initiative

**Notes:**
Background

How is the US Medicare doing?
How is the VA doing?
Institute for Healthcare Improvement (IHI) initiative

## All Cause Readmission: Medicare

**Medicare Quality Monitoring System (MQMS) Report: Heart Failure, 1992-2001**

**Notes:**
All Cause Readmission: Medicare

## HF Readmission Rates: Medicare

**HF Readmission Rates: Medicare**

**Medicare Quality Monitoring System (MQMS) Report: Heart Failure, 1992-2001**

**Notes:**
HF Readmission Rates: Medicare

## HF Readmission Rates: Medicare

**HF Readmission Rates: Medicare**

**Medicare Quality Monitoring System (MQMS) Report: Heart Failure, 1992-2001**

**Notes:**
HF Readmission Rates: Medicare

## VA Heart Failure 30-Day Readmission

- Heidenreich, CHF QUERI 2006

**Notes:**
VA Heart Failure 30-Day Readmission

## Regional Variation: HF Readmission in Medicare

**Medicare Quality Monitoring System (MQMS) Report: Heart Failure, 1992-2001**

**Notes:**
Regional Variation: HF Readmission in Medicare

## VA Heart Failure 30-Day Mortality

- Heidenreich, CHF QUERI 2006

**Notes:**
VA Heart Failure 30-Day Mortality

## Medicare Heart Failure Mortality

**Medicare Quality Monitoring System (MQMS) Report: Heart Failure, 1992-2001**

**Notes:**
Medicare Heart Failure Mortality

## Summary of Administrative Data

- Apparently Stable readmission rates
- Can we improve?

**Notes:**
Summary of Administrative Data

Apparently Stable readmission rates
Can we improve?

## Slide 13

**Notes:**
Protecting 5 million Lives From Harm

## The Institute for Healthcare Improvement (IHI)

- Save 100,000 lives campaign
- Reduce hospital mortality
- Rapid response teams
- Better acute MI Care
- Prevent adverse drug events
- Prevent central line infections
- Prevent ventilator-associated pneumonia
- Prevent surgical site infections

**Notes:**
The Institute for Healthcare Improvement (IHI)

Save 100,000 lives campaign
Reduce hospital mortality
Rapid response teams
Better acute MI Care
Prevent adverse drug events
Prevent central line infections
Prevent ventilator-associated pneumonia
Prevent surgical site infections

## 100K Lives Campaign

- 3100 Hospitals participated
- 18 months
- 124,000 lives saved

**Notes:**
100K Lives Campaign

3100 Hospitals participated
18 months
124,000 lives saved

## The Institute for Healthcare Improvement

- Many more patients are _**harmed**_ than killed
- 37 million hospitalizations/year in the US
- 40-50 injuries/100 admissions
- 15 million are harmed/year in US hospitals
- 40,000 / day
**Goal:  ****	****Eliminate harm to 5 million ****	****	****	****	****patients over the next two years**

**Notes:**
The Institute for Healthcare Improvement

Many more patients are harmed than killed
37 million hospitalizations/year in the US
40-50 injuries/100 admissions
15 million are harmed/year in US hospitals
40,000 / day

Goal:  Eliminate harm to 5 million patients over the next two years

## IHI Definition of Medical Harm

- 	Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.

**Notes:**
IHI Definition of Medical Harm

Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.

## IHISave 5 Million Lives From Harm 

- Prevent pressure ulcers
- Reduce MRSA
- Prevent harm from high-alert medications
- Reduce Surgical Complications
**Deliver reliable **_**evidence**_**-**_**based**_** care for heart failure**
- Get boards on board

**Notes:**
IHI Save 5 Million Lives From Harm

Prevent pressure ulcers
Reduce MRSA
Prevent harm from high-alert medications
Reduce Surgical Complications
Deliver reliable evidence-based care for heart failure
Get boards on board

## IHI 5 Million Lives Campaign: Heart Failure

- Goal:  Deliver reliable evidence-based care for congestive heart failure ... to reduce admissions.
- Reduce the readmission rate by 50% by December 2008

**Notes:**
IHI 5 Million Lives Campaign: Heart Failure

Goal:  Deliver reliable evidence-based care for congestive heart failure ... to reduce admissions.
Reduce the readmission rate by 50% by December 2008

## Discharge Checklist

- Reconcile Medications
- Teach Back
- Follow up phone call in 48 hours
- Medication check
- Physician visit
- 1 week for average risk patients
- 48 hours for high risk patients
- Case management for high risk patients

**IHI 5 Million Lives Campaign**

**Notes:**
Discharge Checklist

Reconcile Medications
Teach Back
Follow up phone call in 48 hours
Medication check
Physician visit
1 week for average risk patients
48 hours for high risk patients
Case management for high risk patients

## Heart Failure Key Interventions

- Measure Left Ventricular Ejection Fraction (EF)
- ACE inhibitor or ARB at Discharge if EF<40%
- Anticoagulation if Atrial Fib. at Discharge
- Influenza vaccine
- Pneumoccocal vaccine
- Smoking Cessation counseling
- Discharge instructions

**CMS: in 2005 only 54% of eligible patients received all interventions**

**IHI 5 Million Lives Campaign**

**Notes:**
Heart Failure Key Interventions

Measure Left Ventricular Ejection Fraction (EF)
ACE inhibitor or ARB at Discharge if EF<40%
Anticoagulation if Atrial Fib. at Discharge
Influenza vaccine
Pneumoccocal vaccine
Smoking Cessation counseling
Discharge instructions

## Heart Failure Other Interventions to Consider

- Beta-Blocker at Discharge if EF<40%
- Discharge Contract
- Statins for coronary disease
- Spironolactone for certain high risk patients

**Notes:**
Heart Failure Other Interventions to Consider

Beta-Blocker at Discharge if EF<40%
Discharge Contract
Statins for coronary disease
Spironolactone for certain high risk patients

## The VA Does Well on Medication Use for Heart Failure

**% of Heart Failure Patients**

**The VA Does Well on Medication Use for Heart Failure**

- Heidenreich, CHF QUERI 2005 data

**Notes:**
The VA Does Well on Medication Use for Heart Failure

## Questions

- How many patients are called within 48 hours of discharge?
- How many are seen by a provider within 2 weeks?  1 week?
- Have sites improved follow-up without an increase in staff?
- If so, what was done?
- Have you eliminated advance appointments to make room for post-discharge visits?
- Are the IHI goals (1 week follow-up) worth pursuing?
- Possible collaborative of interested sites

**Notes:**
Questions

How many patients are called within 48 hours of discharge?
How many are seen by a provider within 2 weeks?  1 week?
Have sites improved follow-up without an increase in staff?
If so, what was done?
Have you eliminated advance appointments to make room for post-discharge visits?
Are the IHI goals (1 week follow-up) worth pursuing?
Possible collaborative of interested sites