Implementing H2H in the 

H lth ea

Care

S t ys

tem

Paul Heidenreich MD, MS

Anju Sahay PhD

VA Palo Alto

10/30/2012
Presenter Disclosure Inform

• We will not discuss off label use or investigational use in m

presentation

• We have no financial relationships to disclose
Outline

Background Background on Heart Failure Failure in the 

VA’s interest in H2H

Heart Failure Network

Randomized trial of encouraging encouraging H

enrollment

Whi hc h it l ospitals enroll d? e

What did they do?

Was there an impact of H2H on outco
Background on

U.S. Heart Failure

Population Hosp

Group Prevalence Incidence Mortality Disch

Total 5 300 000 660 000 284 965 1 084 

population 5,300,000 660,000 284,965 1,084

VA prevalence near 140,000 or 2.6%

1American Heart Association. 2008 Heart and Stroke Statistical

American Heart Association. 2008 Heart and Stroke Statistical

Update. Dallas, TX: American Heart Association; 2008. 

2Hunt SA et al. ACC/AHA guidelines for the evaluation and 

management of chronic heart failure in the adult. 2001. 
Projected Costs of Heart Fa

Fa

907080

ars)

506070

008 Dolla

304050

 of $ (20

102030

Billions

0

2010 2015 2020 2025 2030

2010 2015 2020 2025 2030

Heidenreich, 
Estimated Estimated Direct and Indirect Indirect Costs of 

53%

Hospitalization

$18.8

Total C

$34.8 

Nursin

7%

14%

Nursin

$

8%

8% 10%

7%

Lost Productivity/

Mortality*

Physicians/O

Profession

$3.1

Home Healthcare

$3 2

Drugs/Other 

Medical Durables

Profession

$2.3

$3.2 $3.1

*Lost future earnings of persons who will die in 2008, 

discounted by 3%AHA. Heart Disease and 

Stroke Statistics—2008 Update
Heart failure 30‐day Risk‐Standard

Readmission Rate Distribution

Krumholz, H. M. et al. Circ Cardiovasc Qual Ou
30 Readmissions (All Cause) Dist

for VA Facilities

Excludes Facilities with < 100 HF discharges over 2 years.
30 Readmissions (HF Principa

Distribution for VA Facilitie

Excludes Facilities with < 100 HF discharges over 2 years.
Hospital to Home (H2H

Excellence in Transition

H2H Core Concepts H2H Core Concepts

• Post-discharge medication management. P

not l h t th di ti 

t only 

have access 

to the proper medication

to be properly educated on how to use them. 

• Early follow Early follow-up. Discharged patients should h

Discharged patients should h

up visit scheduled within a week of discharge, 

the means of getting to that appointment. the means of getting to that appointment.

• Symptom management. Patients must recog

si

g yp q 

ns and s

y

m

ptoms that re

quire medical atten

as the appropriate person to contact if those signs/symptoms appear.
Early Follow Up and Readmi

Readmi

Hernandez, JAMA 
Follow‐Up Within 7 Days and Ou

Ou

2025

P<0.05 for Read

1520

or Died

10

admitted 30 

30 

5 % Re0

Q1 (<32%) Q2 (32‐38%)Q3 (39‐45%) Q4 (>45%)

Hernan

Quartiles of Hospitals based on % of Patients Seen in 7 days
Goal

Reduce 30 day, all-cause, risk standardized readmission rates (for patients discharged with cardfor patients discharged with card

conditions by 20% by December 2
VA and H2H

• VA signed on as a strategic partner

• H2H mentioned mentioned on calls to VISN and f

f

leadership

• CHF QU I ER recogni d ze the opportunit

implement H2H through the VA Heart 

Network.
CHF QUERI: VA Heart Failure Failure Ne

Ne

• Id f enti y a group of provid /d ers a minist

with an interest in heart failure

– >800 individuals– 150 facilities– 1‐12 members members at each facility facility

• Web based teleconferences, teleconferences, periodic periodic 

new and surveys
VA HF Network as a Commun

Practice

• Defined by E. Wenger:

– A g p rou of p p eo le who share a craft and

profession

• Exists due to interest interest of members members• Domain: Heart Failure Care and Qualit• Interaction: members learn from each • Practice: Practice: Members Members are actively actively involve

involve

practice or quality improvement.
HF Network Members

PROVIDERS P

Physician (Staff) - HF specialists and non HF specialists and non-specialists specialists 

Nurse / Nurse Practitioner Nurse / Nurse Practitioner 

Chief of Cardiology Chief of Cardiology VISN Contact (Chief Medical Officer, VISN Quality Mgt Officer, VISN Patient Safety Officer VISN Care Coordinator etc )

VISN Patient Patient Safety Officer Officer, VISN Care Coordinator Coordinator, etc.)

Chief of Medicine Chief of Medicine Others (Cardiology Tech, Case Manager, Clinical Care Coordinator, Telehealth Coordinator Primary Care Manager etc )

Telehealth Telehealth Coordinator Coordinator, Primary Primary Care Manager Manager, etc.)

Pharmacist Pharmacist Facility leadership (Associate Chief of Staff, Associate Quality Management Officer, Patient Safety Officer, etc.)Psychologist Psychologist 
HF Network Network Participatio

Participatio

100%

By Facility

80%90%60%70%

lities

40%50%

VA FaciH

LN

20%30%

% 

0%

10%

Network Participation
HF Network Network Participation Participation 

90%

Academic Characteristic

P NS P 0 02 P 00

70%80%

P=NS P=0.02 P=0.07

60%70%

lities

40%50%

VA Faci

20%

% 30%

0%

10%

ACGME COTH Board Cert >75%
HF Network Network Partici Participation 

Volume

300350

P=0.02 P=0.006

250150200

N

100150

0

50

Bed Size HF Discharges (2 years
HF Network Network Partici Participation 

Quality of Care

100%

80%40%60%

N

20%40% 

0%

LVEF docum. ACEi if LVEF<40 Disch. Educ. Smoking Co

CMS and Joint Commission Inpatient Performance Measu
Purpose

• Use the Heart Failure Network to help

implement the Hospital to Home Initia

• Implementation Science Questions:

– Can CHF QUERI use the VA HF Nt k e wor 

increase enrollment in H2H?

– What types of programs are implemente– How much did it cost?
Methods

• Identified 124 facilities with 100+ hea

discharges over 2 years

• Randomized 1:1 to usual care of heart 

network activation

– Hospitals first paired by number of beds 

balance size
Usual Care

• H2H presented (5 minutes) on two na

conference calls

– Chief of Staff, Director (100+ attendees)– Regional Regional (VISN) Chief Medical Medical Officers Officers (o

each of 21 regions in the US)
Intervention (HF Network Network Activ

Activ

• Emails to HF Network members

• Web based teleconferences teleconferences announci

announci

(1/2010)

• Follow up survey asking what is pl 

ann

• Individual facilities presented p g ro res

web based teleconferences

• S d econ survey asking st t a us of proj t ec 

(both intervention and control)
Outcome

• Primary: Hospital enrollment on ACC/

website

• Initiated project in response to H2H• Any pl d anne or i ii d n t ated project that

addresses H2H goals
Baseline Outcomes (200

Intervention Control

20%

P=NS f

10%

0%

30 D HF R dii 30 D M 

30 Day HF Readmission 30‐Day Morta
H2H Enrollment Enrollment at Six Mon

100%

Intervention Control

80%40%60%20%40%

0%

Randomized Group
Network Activation Contro

8060

t (%)

40

rollmen

20 cility En

0

Fa

0123

Month
New Projects Projects Due to H2

30

Intervention Control

2025

N15

5

10

0

Initiated Planned
VA Facilities Facilities Plans for H2

No Response Ongoing ProjectPlanned due to H2H In Response to H2

80%90%

100%

60%70%30%40%50%10%20%

0%

Intervention Control
H2H Enro e

llm 

Subgroup N Network Activation Tertiary Care Facility 50 73% Secondary Care Facility

72 40% 

COTH Member 60 61% Non COTH Member 62 48% Bed Size >=250 56 54% Bed S e 50 iz <250 66 5 %4 U.S. Region # (%)

Northeast 21 44% Midwest 32 55% South 44 54% West 25 58% 
45

503540

s

253035

of Projects

152025

Numbero

5

10

15

0

Medication Early follow-up SymptomManagement Recogniti
Cost of H2H

• Cost to CHF QUERI of encouraging enroll

$10,200

• Project Costs at Facility

– Responses Responses at 1 year for 20 of 30 new projec

projec

– Mean 19 ± 18 hours per week of all staff co– N i urs ng, Care C di ti oordination were most f 

requ

used

– 85% of f iliti acilities provid de no st ff a resources

– 57% of facilities provided space
Phase 2

• Control facilities now receive “HF Netw

Activation

• Similar schedule of web based calls

announcing announcing the project project, surveys surveys and f

f

presentations demonstrating success.
VA H2H Enrollment

100%

Intervention Control

80%40%60%20%

0%

6 Months 15 Month

Months 15 Month

All Facilities Targeted After 6 Mo
Network Activation Con

8060

ment (%)

40

y Enroll Facilit 20

0

01234567

Month Following the Trial Month Following the Trial
Who Enrolled Enrolled in H2H?

Subgroup N Enrolled in H2H Enrolled in H2HTertiary Care Facility 52 75%Secondary Care 74 58%FacilityCOTH Member 62 73%Non COTH Member 64 58%Bed Size Bed Size >=250 59 68%Bed Size <250 67 63%U S Region # (%) U.S. Region # (%)

Northeast 22 71%Midwest 35 63%S th ou 44 61%West 25 64%
Who Enrolled Enrolled in H2H?

Cardiology Section Surve

Subgroup N Enrolled in 

Enrolled in 

HF Clinic 67 73%No HF Clinic 48 56%Discharge Calls 81 72%No Post No Post DC Calls DC Calls 34 53%Invasive Cath 69 75%*No Invasive Cath 41 54%*p=0.03
Baseline Outcomes (2008) and J

H2H

Joined H2H Did not Join H2H

20%10%

P=0.96 P=0.07

0%

30 D HF R dii 30 D M t 30 Day HF Readmission 30‐Day Morta
Baseline Process of Care

and Joining H2H

100%

Joined H2H Did not Join H2H

80%

100%

60%20%40%

0%

ACEi if EF<40 EF Docum. Disch Instr. S
Can We Detect an Effect of 

• Primary outcome: 30 day readmission

• Secondary outcomes

– 7 day follow‐up– H il osp tal days (30 days and 1 year)– Mortality (30 days)
Methods: H2H Impact

• Hospital level analysis

• Three time periods

– 1 year before H2H– 0‐6 months after i ii i n t ating H2H– 6‐18 months after initiating H2H

• Weighted for number of admissions• Propensity Propensity score: to enroll in H2H
VA 30‐Day All Cause Readmis

(Primary Outcome)

Joined H2H Did not Join H2H

40%20%30%

All P=NS

10%

0%

Y P H2H 0 6 M th 6 18 Year Pre H2H 0‐6 Months 6‐18 m
VA 30‐Day Heart Failure Failure Readm

Readm

Joined H2H Did not Join H2H

20%10%15%

All P=NS

5%0%

Y P H2H 0 6 M th 6 18 Year Pre H2H 0‐6 Months 6‐18 m
VA 7‐Day Face to Face

Follow‐Up

Joined H2H Did not Join H2H

16%20%

P=0.29 P=0.04

12%

4%8%0%

A F t F C di lAny Face to Face Cardiology
VA 7‐Day Face to Face

Follow‐Up: All Visits

Joined H2H Did not Join H2H

16%20%

All P=NS

12%

4%8%0%

Y P H2H 0 6 M th 6 18 Year Pre H2H 0‐6 Months 6‐18 m
VA 7‐Day Face to Face

Follow‐Up: Cardiology

Joined H2H Did not Join H2H

8%4%6%

P=0.85 P=0.04 P=0

2%0%

Y P H2H 0 6 M th 6 18 Year Pre H2H 0‐6 Months 6‐18 m
Change in 7‐Day Follow‐U

6-18 Months after H2H - Baselin

Joined H2H Did not Join H2H

6 18 Months after H2H Baselin

12%

sitsP=0.60 P=0.002

6%9%

7 Day Vis

3%

crease in 

0%

Any Face to Face Cardiology

Inc

Any Face to Face Cardiology
Hospital Days (All Cause) Follo

Discharge

Joined H2H Did not Join H2H

12 015.0

ital

9.0

12.0

e HospP=0.007 P=0.0

P=0.16

3 06.0

ys in th

0.03.0

P i Y 30 D P t DC 1 Y 

Day

Prior Year 30 Days Post DC 1 Y
Hospital Days (Heart Failure) Fo

Discharge

Joined H2H Did not Join H2H

4 05.0

ital

3.04.0

e HospP=0.007 P=0

1 02.0

ys in th

0.01.0

30 D P t DC 1 Y P 

Day

30 Days Post DC 1 Year P
VA 30‐Day Mortality Mortality

Joined H2H Did not Join H2H

20%10%

All P=NS

0%

Y P H2H 0 6 M th 6 18 Year Pre H2H 0‐6 Months 6‐18 m
Propensity Scoring

• Similar results to univariate findings

• R squared squared for predicting predicting enrollment enrollment 0
Summary 1

• A maj y orit of VA hospitals have enroll

H2H

– Larger, Larger, academic academic facilities facilities more likely to 

• Enrollment and project development 

enhanced enhanced through through the use of an existi

existi

provider network

– 30% of h it l ospitals h da ongoing proj t ec s

– 20% have started a project due to H2H

– 10% planned to start
Summary 2

• Some evidence that H2H improved ca

– More visits with cardiology– No change in readmission readmission– Less hospital days over 1 year

• Limitations

– Non randomized comparison of H2H enr– Power limited by number of VA Hospital

– Non‐VA care not included

– Many of H2H processes already adopted