**Transcript of Cyberseminar**

**QUERI Implementation Research**

**Implementation of the Hospital to Home (H2H) Heart Failure Initiative**

**Presenters: Paul Heidenreich, MD, MS, and Anju Sahay, PhD**

**October 30, 2012**

**Implementation of the Hospital to Home (H2H) Heart Failure Initiative**

**October 30, 2012**

Moderator:We are at the top of the hour so I would like to introduce our two speakers: we have Dr. Paul Heidenreich and Dr. Anju Sahay joining us both from VA Palo Alto Health Care System. So at this time I’d like to turn it over to you Paul, are you ready? 

Dr. Paul Heidenreich:Yes. 

Moderator:Great. You’ll see a pop-up, go ahead and click show my screen and you should be set.

Dr. Paul Heidenreich:Okay. 

Moderator:Great. 

Dr. Paul Heidenreich:Well I want to thank everyone for joining. On behalf of myself and Anju Sahay, and CHF QUERI, we are pleased to discuss with you our efforts and observations in implementing the Hospital to Home system (H2H) in the VA Health Care System. 

I’ll first mention that we have no disclosures related to this presentation. 

I’ll begin by discussing a small amount of background, particularly for those on the call who may not be that familiar with heart failure. We’ll then discuss how the VA became interested in the Hospital to Home and how the Hospital to Home initiative came about. Anju Sahay will discuss then our heart failure network and how we decided to use this to help implement the Hospital to Home Network. We’ll discuss then a randomized trial we conducted of encouraging H2H enrollment among VA facilities, then we’ll discuss the results in terms of how successful that was and what they did. And then finally we’ll finish with our overall estimate of the impact of Hospital to Home on outcome in the VA Health Care System. 

So heart failure, as many of you know, is a very common and costly condition. In the United States the prevalence is about 5.3 million. In the VA, again depending on how you define it, and we here defined it as at least two visits for heart failure within a year, that number is about 140,000 or about 2.6% of the overall population. It has a very high mortality, one million discharges per year and over $30 billion in costs per year. 

In fact the costs, direct and indirect combined, are expected to increase substantially over the next twenty years, just due to the increase in the age of the population. So even if we didn’t have anything else happen to our society, we would see this marked increase just because of the older population in the United States. So it is a wake-up call, I think, that we do need to come up with ways of improving the cost of care. 

Many of these costs are in the inpatient setting. And this slide shows the distribution of those costs as identified, approximately four or five years ago. And I think it’s still true today that over half of the costs are for hospitalization. Now when one looks at hospitalization, people identify that many are re-admitted. And this is data from Harlan Krumholz for Medicare population showing a wide distribution of readmission rates that were again, not only high but also spread out, with roughly about 24-25% of the population being re-admitted within thirty days after a hospitalization. And the fact that we do see this distribution suggests that some who are up near the 30% range may be able to learn something from those that are down near the 20% range. At least that was the hope. 

When we look in the VA health care system, we’re seeing something similar. We see that again this shows the distribution in a slightly different way, each column is a different VA facility with at least 100 heart failure discharges over two years. Now we’re looking at their all cause 30 day readmission and we see that it varies from about 15% on the low end to over 30% on the high end with the mean in there maybe a little bit below 20 some percent, though again, a similar rate for all cause admissions following a heart failure hospitalization. And when one looks at heart failure-specific hospitalization, again did they come back specifically for heart failure? We see an even greater variation potentially from four percent up almost a four-fold or more increase from the lowest to the highest facilities. Again suggesting that the care is different across our VA facilities and it’s possible that some care best practices could be transferred to other facilities leading to better care.            

So because of these observations, the high readmission rate, the wide variation in readmission rate, the Institute for Health Care Improvement along with the American College of Cardiology developed the Hospital to Home Excellence in Transition Initiative. And again, it was based on the concern of this revolving door that many patients are leaving unprepared for this transition, the system’s not doing very much for them, and then they end back up with a preventable hospitalization. 

So to counteract this, to address this, the H2H developed three core concepts: Post discharge medication management, early follow-up, and symptom management. The post discharge medication management is the idea that patients need to have access and need to know how to use their medications appropriately. They need to have early follow-up in some form within a week for the average patient. And that symptom management – for sympton management, the patient must be able to recognize the symptoms of deterioration and know what to do when those occur, know who to call, how to get a hold of someone if that were to occur. 

So they focused on these three areas and primarily because I think a lot of it is non-randomized data, but there is some data to suggest that these things will be effective. Here are some again, non-randomized data on early follow-up in readmissions published two years ago where they looked at Medicare patients and first saw very large variation in follow-up within seven days in some form, within the Medicare population. So again, a range from under 20% to 60% and then when one broke those down into quartiles, there was a small but statistically significant increase in readmission for that lowest quartile group where patients were being seen less than 32% of the time compared to the other facilities. 

So again, it wasn’t a ... we were not looking at a huge impact here, but at least there is some data to suggest that the seven day follow-up that is recommended by H2H will be effective. 

Their goal was to reduce thirty day all cause risk standardized readmission rates for patients discharged with cardiac condition by 20% by December 2012, so two months from now. So this was launched at the end of October of 2010 and so the goal was, within two years to have this reduced, the readmission rate by 20%. 

Now H2H asked for strategic partners and many people signed on and the VA Central Office agreed to this, thought it was a good idea and wanted to be a strategic partner. But beyond that, there were no requirements, no mandates that any facility do anything regarding this. In fact, sort of the extent of it at the time was that H2H was mentioned on calls to VISN and facility leadership but it was up to them at that point to go forward and initiate projects. And I’ll let you know what enrollment means is representative of the facility, go the H2H website, and basically confirm their dedication to those three areas, to agree to work on at least one of those areas if they are not doing it already, to start new projects to improve care in one of those three areas. And then to periodically respond to surveys that the H2H group would send to them. 

Now our group at CHF QUERI recognized that there was an opportunity here to do more than just go the top down method that I think is common within the VA, and that we could use our existing VA Heart Failure Network to combine that top down with more of a bottom up approach to help implement H2H within the VA health care system. So at this point, I’m going to turn it over to Anju Sahay who is then going to discuss the VA Heart Failure Network and some of our initial findings with the network. So Anju, please go ahead. 

Dr. Anju Sahay:Thanks Paul. So I believe everybody can see my slides. Correct. Okay. So I’ll be talking about the heart failure network which has been formed by the CHF QUERI and we have facilitated the implementation of the VA H2H Initiative to the Heart Failure Network at all the facilities. 

So in July 2006 we formed this Heart Failure Network, or HF Network, which is a social, informal network of VA providers who are interested in improving the quality of care for heart failure patients. We currently have over 800 providers – specifically 862 providers at 150 facilities. And at each facility, our number of members or providers range from one to two providers at each facility. The purpose... we use this Heart Failure Network in a variety of ways and in our presentation, in this context we have been using this Heart Failure Network to facilitate the implementation of the VA H2H Initiative. 

This network operates through web-based teleconferences or live meetings. We have them every two months, which the format typically is we share information, any updates, and then there are two presentations typically one focusing on a quality improvement initiative and the other one on research findings on this project. And these presentations are made by members of the Heart Failure Network at different facilities. So we also have emails and surveys which we do through the Heart Failure Network.  

Now we view the Heart Failure Network as a community of practice. These communities of practice are a type of informal learning organization or organizations – they can be more than one community to practice within a formal organization. According to Wenger, communities of practice consist of groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis. These communities of practice are gaining popularity in the health sector and there is growing evidence of these communities of practice. They are developing and functioning within social networks, such an example is our Heart Failure Network which has this community of practice focusing specifically on improving the quality of heart failure care through the involvement of providers or community practice members. And through this involvement, the members are learning from each other through explicit and tactic knowledge. They are interacting and the members are actively involved in heart failure practice or quality improvement projects. 

This slide shows the composition of the current heart failure network members. The members are multi-level within the VA system and multi-disciplinary. We have physicians, chiefs of cardiology, chiefs of medicine, nurses and nurse practitioners, pharmacists. We have facility level members and VISN level members who include administrators. 

We have looked at the participation by the members at the facility level and as you can see, about 20% of the facilities, though we have members there, the members are not participating. About 40% of facilities do have members, but they are participating at a low level, and the remaining 40% have members are participating at the high level. 

Let me specify what really we mean by participation. We define participation as being actively involved in at least one activity of the Heart Failure Network. So by just being a member, that means they are receiving all communications and information, but they may not be actively participating in the activity. And again, participation is, what we are talking here is active participation. That means they have attended at least one session or responded to an email or participated in other activity. We do know some of the members are participating passively because we know they go to our website and access resources that we’ve learned through formative evaluation. But in this context we are talking about active participation by our members. 

We’ve also looked at the academic characteristics of the facilities, VA facilities in the Heart Failure Network, and participation in this network by the members. Specifically we’ve, here we’re looking at the ACGME which starts for the Accreditation Council for Graduate Medical Education. This body is responsible for accrediting the majority of graduate medical training programs for physicians in the U.S. The other dimension is COTH which stands for Council for Teaching Hospitals and the board certifications from over 75%. And as the slide shows, consistently, facilities which have higher percentage of ACGME, COTH, and board certification are participating more actively in the Heart Failure Network. One reason could be the smaller facilities have fewer providers and they have less time to participate actively in the Heart Failure Network.                

Similarly, we’ve also looked at the volume, the bed size, and the heart failure discharges at these facilities and linked that to participation in the Heart Failure Network. Like before, our facilities which are larger and have more discharges, the members, or providers, at these facilities participate much more actively compared to the smaller facilities. 

This slide looks at the mission critical measures for heart failure inpatients by CMS and Joint Commission. And these four measures are LVEF documentation - that’s left ventricular ejection fraction, documentation offered. And ACEi if LVEF is less than 40. Discharge education and smoking counseling while they’re still in the hospital and inpatients. We see across board that all across and all types of facilities that they are doing very well. But if you wanted to look very closely then we see definitely that facilities that are participating more have, are doing better but again, across board, all facilities are doing very well in that. 

I’ll hand it back to Dr. Heidenreich to continue the presentation. 

Dr. Paul Heidenreich:Okay, thank you Anju, so our thought was that given this Heart Failure Network which included again many front line clinician providers and interested in heart failure and quality managers at their facilities, that we would want them involved as they would most likely be those who would be implementing any particular project related to H2H. 

So the purpose of our first randomized trial was to see if we could use the Heart Failure Network to help implement the Hospital to Home initiative. We wanted to see if we can encourage facilities to enroll using the Heart Failure Network and then we wanted to see what types of programs they implemented and give an estimate of the resources used to do this. 

So we identified 124 VA facilities with at least 100 heart failure discharges over the last two years. Again this was in 2010 and we had launched this in ... in the start of 2011. Again a few months after the main launch of the H2H initiative. And hospitals are randomized 1:1 to usual care for Heart Failure Network activation. Our usual care of Heart Failure Network activation and we at first paired the facilities by number of beds to make sure we had balanced on size of the hospital. 

Now the usual care group received what I had mentioned previously in that H2H was presented by CHF QUERI on two national calls, one was the Chief of Staff Director call, and one the VISN CMO Chief Medical Officer call. And where it was mentioned that the VA was a strategic partner and facilities were encouraged to enroll in this. 

Now the intervention again, we first emailed Heart Failure Network members in the randomized facilities, we set up web based teleconferences announcing H2H, we did follow-up surveys asking what were planned and then several months into it, we asked individual facilities to present their progress on the web based teleconferences so that facilities could then learn what other facilities had done. So we sort of had the early adopters give a discussion. 

And the second survey follow up was asking about the status of the projects. And for this then we asked both intervention and control sites if they had started any projects related to H2H. Now the main outcome would be hospital enrollment on the ACC/IHI website. So that was out of our control, we do have affiliations with that group so they would periodically let us know all the different VA facilities around the country that had enrolled. 

Secondary outcomes were projects that were initiated in response to H2H and this is through our surveys of Heart Failure Network members at each site including both initiated plan and planned projects related to the H2H goals. 

So looking at some baseline characteristics, this slide just shows the outcome in 2008, sort of leading up to it. And we see that the facilities are reasonably balanced, the mortality, the 30 day mortality, and 30 day readmission for heart failure, not all cause readmission, was very similar between the two groups as we would have expected. 

Our results – we’re going to jump to the main results here and that is, we were at six months successful for the primary outcome is at least getting facilities to enroll. So we had pretty much half of the facilities were in the intervention group enrolled compared to about ten percent in the control group. So if we look at that over time, and that’s shown on this graph, we see enrollment in blue for those randomized to network activation and in red for the control group – that there’s early and consistent increase in enrollment up to about four months and then it plateaued. But it was a clear demonstration that at least for this type of intervention, we could get facilities agreeing to be involved by activating the Heart Failure Network members, members of the disease-related network. 

We then asked facilities if they had initiated or planned projects related to H2H, again this was at six months. And as expected, there were more facilities enrolled, there were more projects from the intervention sites both that were initiated in response to H2H and planned in response to H2H. Again, if we just look at six months after our initial intervention, this slide shows first whether we are able to get a response from the facilities and the status of their ongoing or initiated projects related to H2H.            

So a couple of things, one you can see is even though we again.. we randomized all these facilities and as you may have figured out, the facilities did not agree to be involved up front. We decided okay, for these 60 some facilities, we are going to try to encourage them. And for a certain percentage we’re just not going to get a response, and we knew that going in. We were able to get a greater response from the intervention facilities and we do see here that a fair number initiated projects and a fair number also had planned projects. I think also what’s important to note is that there’s a lot of ongoing projects already in existence that addressed the H2H goal, both at the intervention and the control group. In fact, if you just look at the responders, approximately half of the H2H .. of the potential H2H projects were already, you could say were already in place. The VA was already doing those things related to those three topics. 

If we look at some other characteristics of who enrolled, we see that enrollment broken down by whether they’re in the network activation group or the control group for different subgroups of facilities. So we see that across the board, network activation has greater enrollment than the control group but that it was also even more so in Tertiary Care Facilities and in the cost membership.. those who are cost members. We didn’t see any obvious difference here on bed size, at least among the network activation groups and again there was also no statically significant mediator of region of the country. 

If we look at the type of project that was initiated, the data are shown on this slide. Again broken down by medication management, early follow-up, and symptom recognition. Again medication management is when the facility said they had a project designed to either educate the patients at the time of discharge regarding their medications and have a way for the patients to make sure they have adequate medication and know what those were. Early follow-up was a project related to increasing seven-day follow-up, again symptom recognition was something related to having patients know what their symptoms were and who to contact if there was a problem that occurred. And you can see, across the board it’s fairly consistent. There were more projects planned, initiated, and ongoing that we could document among the network activation group compared to the control group. 

Well what about the cost of this? Well we kept track of the amount of work put in by the CHF QUERI personnel encouraging Heart Failure Network numbers and facilities to enroll. But that was pretty inexpensive, we were able to .. we estimated it was a little over $10,000 to encourage the facilities and the network members to enroll. So at the cost per facility and the cost per enrollment, that was pretty inexpensive. I don’t know if I had mentioned that actual enrollment did not incur any cost to the facilities. And while they were asked to complete surveys, they did not have to provide any raw data and that the actual – whether the project worked or not was determined by looking at Medicare data separately, or in our case the VA data. 

When one looks at the cost to the facility and resource use, we surveyed different facilities, particularly those who had started new projects, and about a year and a half in.. And those with thirty, the thirty that had new projects we had a response on 20 of those. And they reported that among all staff, they spent about 19 hours per week on average working on these H2H related projects. Nursing and care coordination were the most frequently used staff. Some did use primary care providers, there were pharmacists that were also used. But nursing and care coordination were the most. 

I think of significant interest was that 85% of the facilities provided no staff resources. So while 15% of facilities either hired some new people or they reassigned people to this, most said “Okay, that’s a good idea, but do it on top of your current responsibilities.” I should say that so many of these, that’s exactly what most of these facilities did, and I think it does go to show that you do need those front line people motivated, you need local champions in order to get projects like these going. 

I will say 57% of the facilities provided space. So while they didn’t provide people or personnel, they were often able to find locations for whether it’s a clinic or some other projects. So our conclusion from that trial was that we were successful in using the Heart Failure Network to get facilities enrolled, to get projects going. Many of those projects though were primarily through the efforts of a local champion with some but not a lot of help from the facility – facility leadership. 

So our next.. after this, seeing the success of that and given that the VA did want all facilities enrolled, we after six months we then did our intervention on the control group. So we sort of at that point, lost our chance of seeing a difference in outcome, but we sacrificed that in order to try to get as many facilities enrolled as we could. So we did the same schedule of web based calls, announcement of projects, etc. And we saw here, you could see at six months, this is the slide I showed before that there was a clear impact of encouraging the facilities. By fifteen months, that difference was pretty narrow. The control facilities have signed up. I think again, showing our ability to impact the Heart Failure Network and again, this shows at the end of our six month trial, how the control group caught up to the network activation group. And at this point, we’re actually up over 80 facilities, VA facilities that have enrolled in some way. 

In terms of who enrolled, when we combine the control and intervention groups together, now almost two years out or more, we see that Tertiary Care Facilities were more likely to enroll, membership in council and teaching hospitals, so the academic facilities were more likely to enroll, not a clear difference in bed size and not a clear difference in regions of the country. We also had data from the Cardiology Section Survey from early 2011. And the different section chiefs of cardiology were asked to, where they existed, or if not, then the medicine service chiefs were asked to provide information on cardiology services. So we were able to see that places with an existing heart failure clinic were likely to enroll. Most hospitals had discharge calls in place for everyone discharged with heart failure, although a significant number said they did not have a standard protocol for discharge calls. And those were more likely to enroll, although these numbers are not statistically significant, except for those facilities that have an invasive cardiac catherization, who did PCI, those facilities were more likely to enroll, so slight differences but not huge differences in facility characteristics.

Now again if we look at our baseline characteristics, and I think again putting everyone in who did and did not join H2H, I think it’s similar to what we saw before, no clear difference going in, in terms of mortality or 30 day heart failure readmission. So it wasn’t just that a facility decided, because they had a high readmission rate, then it was worth joining. It seems that people joined regardless of their readmission rate. And similarly everyone was very high on their, and Anju had shown some of this data earlier, all the facilities are very high on their use of the four process measures inpatients that are tracked by Joint Commission and CMS. So there was no difference there. So our hope was to see if we can detect an effect of H2H and so we chose as a primary outcome that that had already been picked by the main H2H group; that was a thirty day all cause readmission. But we were interested in some secondary outcomes, particularly could we see an effect of seven day follow-up, a process measure that has been linked to less readmission. Could we.. and we’re also [inaudible] with CHF QUERI that there’s some better measures than readmission, one of those potential measures is hospital days and not just a yes, no, were you readmitted? And then of course – mortality. 

So we looked at all these measures and that’s what I’ll show you in the next ten minutes or so. So to do this again, we did a hospital-level analysis to determine hospital rates and then did waiting for the number of admissions in our analyses. We broke up our analyses into three time periods: the one year period before enrolling in H2H, then the six months after the hospital started H2H assuming they did, and then the six to eighteen months after initiating H2H. And again, of course there was a staggered enrollment over time, so to pick the control group, we just looked at them at the median time point for the facilities that enrolled in H2H and assumed that was their time point for the control group. 

Unfortunately, we could not show an effect on the primary outcome, which was the VA 30-day all cause readmission rate. If we look at the year prior to the index date, which was either the date the hospital enrolled in H2H, if they did enroll, or the median date, as we mentioned for the control group. Again, whether we look at prior six months after or a year after that, we don’t see a clear benefit. If you are an optimist you may say “Oh well it looks like readmission rates are slightly coming down.” Again that’s not statistically significant. But no clear effect of the H2H on the primary outcome of all cause readmission. 

Similarly, if one looks at heart failure readmissions, so these are those who readmitted with a primary diagnosis of heart failure, again we don’t see any clear difference here. Whether you are looking at six months or the six to eighteen month period after enrollment in H2H. 

However, we did see some differences in seven day face to face follow-up for cardiology. So if we look at first, any face to face visit. And again, this doesn’t encompass all types of seven day follow-up. There’s some home based health care, there’s some that are handled by telephone calls. If someone came in and was seen by .. and here we looked at primary care or cardiology. If you went to see neurosurgery that wasn’t included. So what we see that there was a slightly greater use of .. but not statistically, for those in the H2H group, for all cause and it was significant for cardiology. And a lot of borderline, I think there’s a reason to believe that in that a large proportion of our heart failure network are based in cardiology. 

If we look at how this changed over time, we see that seven day visits, face to face visits, clearly increased just in this two-year period of observation. But that there wasn’t a clear effect of being in H2H. And again, so we’re now I think if we looked at the most recent data, now at least a quarter or more of patients are seen face to face in general medicine or cardiology. 

If we just look at cardiology however, we do see at baseline there was no difference but by six months and in six to eighteen months, there was a much greater increase in cardiology face to face visits. Again, this is very small and if this was the only way things were being affected, it’s not surprising that we don’t see any other impact on outcomes. That’s a very small absolute number, that’s only about one percent. 

And then if one looks at the change from baseline, just one more way of looking at it, a change in seven day follow-up rate, baseline to follow-up, again we see the difference for cardiology but not for any face to face visit. Everyone increased but no greater increase for H2H. 

Now to look at the hospital days. Here we’re looking at all cause hospital days. And if we look at the prior year, for patients admitted, we actually do see, for whatever reason, those who joined H2H, they were more likely to have.. the patients who joined H2H, they are more likely to have been admitted in the prior year than those who didn’t join H2H. When we look at the thirty days after discharge, again it’s a very small number of days. One or two days that occur during that thirty day period of hospital care on average. And then if we look at one year, patients are having between seven and nine days in the hospital on average following that and this was significantly lower for those that joined H2H. So I think it’s saying, one is that perhaps many.. and we don’t have the one.. I don’t have the one year readmission rate data to show you. It did not quite reach statistical significance. But I think it’s suggesting that some of these interventions that are put into effect, are going to take longer than thirty days to achieve their benefits, particularly if patients get started on the right medications or at least they don’t stop taking them during the transition period. That effect may take a year or so to see any improvement. 

Again if we look at heart failure specific hospital days. So these are days in the hospital where heart failure was listed as the principal discharge diagnosis. Again actually less than one hospital day on average following an admission for heart failure per patient in thirty days, and then two to three at one year, a similar trend but this did not quite reach statistical significance.       

If we look at mortality – I think not surprisingly we do not see a difference between those who joined H2H and those who did not join H2H, depending on which time period we look at. 

Now I won’t show you these specific results but we did a propensity score then determining the propensity to enroll in H2H given this was a non randomized study, maybe some facilities were much more likely to enroll. And as you know we did see some differences, however the R squared for predicting enrollment was not very high, it was only about .08 so one way to interpret that, those facility characteristics explained about eight percent of the hospital enrollment. 

When we then do a propensity, mass propensity analysis, we see the similar findings related to the univariate analysis. We do not see a difference in readmission rate, we do see a difference in early follow-up for cardiology and we do see a difference in hospital days at one year.        

So our summary findings, and then we’ll open it up for questions is that currently a majority of the VA hospitals have enrolled in H2H. It was the larger and slightly more academic facilities that were more likely to enroll. Although that’s not a strong effect, it was statistically significant. We were able to enhance enrollment through the use of our existing heart failure provider network. That seemed to be much more effective than just usual care which was mentioning it on network calls. And that’s.. while not everyone started projects, we did find that 20% had initiated a project related to H2H, 20% of facilities. Another ten percent planned to start and at least double that amount already had projects ongoing related to H2H. 

Again, while we did not meet the primary end point if you will, of reducing all cause readmission, there was some evidence that perhaps H2H is improving care, given that we did see an increased number of visits with cardiology, and that there were less hospital days over one year. However, of course, there are  some multiple limitations one needs to keep in mind, particularly that this was a non-randomized comparison of H2H enrollment. On the other hand, power is very limited by having only over 100 some VA hospitals, so it’s very hard for us to show small effects that may have occurred in readmission rates or other outcomes. At this point, we have not included non-VA care. So we’re in the process of adding Medicare data, which will give a little more accurate assessment of the actual readmission rates – although we’re not expecting that to significantly change the results. 

And I think perhaps one of the greatest limitation is the VA was already ahead of its time, if you will, in many of these interventions that the VA was already doing a lot of these and there was, in some ways, not a lot of room for improvement. So at this point, I want to thank everyone for their attention and we’ll open it up for questions. 

Moderator:Great, thank you very much. Before we get started on the questions, I just want to make a quick announcement for those of you that joined us after the top of the hour to submit your questions. Simply go to the go to webinar dashboard, on the right hand side of your screen, type your question in under the question section and then press send and we’ll get to it in the order that it was received. The first question we have “What are your plans to evaluate outcomes in hospitals enrolled in H2H?” And this came in fairly early. 

Dr. Paul Heidenreich:Sure. So right, so in addition to what we presented, we will be again adding in.. I think the main thing is we’re going to be trying to add in the Medicare data and see if that impacts our outcomes. I think also we’re going to try to do an analysis of subgroups based on specific outcomes. So it will be interesting to see if facilities that targeted the early follow-up, whether they had success at early follow-up, and whether that explained it or not. Again I think those will be somewhat low powered analyses, but I think those will be some of the next steps that we’ll be taking. 

Moderator:Thank you for that response. The next question: “Was there any patient feedback captured or better understanding of disease and self management?” 

Dr. Paul Heidenreich:We did not capture that at the top level. Now it’s.. and there was no requirement that we get any patient interaction, that the facilities report any types of patient interaction. But we do know that many of the projects the facilities initiated did include patient interaction. But we specifically did not capture any patient imported data. So we don’t know.. while we know sort of some of the details of the project, we don’t actually have the patient level data. 

Moderator:Thank you for that reply. The next question: “Do you know if those who were enrolled in H2H and had improvement in hospital days or cardiology visits actually initiated projects or could this just be by chance?” 

Dr. Paul Heidenreich:Yes, we have not done that.. finished that analysis. I say that’s a very good question to see if we can show that. It could always be by chance, and given that we did not show the primary outcome, I think one should always be skeptical of secondary outcomes. But I think that will be our next step. Now again, as you know we did .. while we did have a fairly good response rate in detail about the specific projects, when we were told about them, there were 40% of facilities that would not tell us what they were doing. And so it will be a somewhat limited analysis, for the outcomes, we have 100% because the facilities are not responsible for providing any of that data. We do know with confidence what their readmission rates were. It’s possible, we could.. we’d be missing projects they’d initiated and just didn’t tell us about. 

Moderator:Thank you for that reply. The next question, this is a clarification of a previous question: “Did the seven day follow-up concentrate on ..”  I’m sorry this is not a follow-up, this is just a clarification on your content. “Did the seven day follow-up concentrate on patient awareness and symptoms?” 

Dr. Paul Heidenreich:Well the .. I think those were two components of the three, three goals of the H2H program, so during that early follow-up, one was expected to also be emphasizing both the medications and the symptoms as well as everything else one might do during that ... an early visit. But just the early visit itself was considered a goal and an outcome for H2H. 

Moderator:Thank you. Next question: “Have you looked at any interaction effect with the availability or intensity of the availability of CHF “Health Buddy” or any post discharge telecare?”

Dr. Paul Heidenreich:I think that’s a very good question and deserves us looking into it. I think we would like to see exactly what mediated these effects and we would like to get a hold of some of the care coordination data to see if that could explain the differences. 

Moderator:Thank you. This is our final question in the queue: “Looking at your data, I wonder if the juice was worth the squeeze? The lack of impact on primary care where I think the emphasis is needed, is striking. I question if a strategy based on improving basic health care – for instance PACT, is a better strategy than a diagnosis specific one for example – H2H?”

Dr. Paul Heidenreich:I think those types of questions should always be examined. And you’re right, I think it’s unclear at this point if H2H was successful. But I think.. I will say, I wouldn’t necessary blame H2H because I think at least they are conducting an evaluation and I think there’s been a lot of interventions done with very little evaluation. And again I think we’ll have a better sense when the national group does their evaluation using Medicare data – they will have a lot more power and be able to see potential differences. But I think that is a very good question and I... perhaps other interventions would be more effective. 

Moderator:Thank you, another question has come in: “Does the QUERI intend to increase the amount of RRP to help fund projects being initiated at local VA sites?” 

Dr. Paul Heidenreich:Again that’s.. we at CHF QUERI don’t control the number of RRP’s but my understanding is that the funding will remain fairly similar for next year for those who are interested in applying for RRP funding. Again those are for projects primarily related to implementation of interventions that have some evidence for effectiveness with the ultimate goal of if they are successful, doing it at a much larger scale. 

Moderator:A couple more questions are coming in: “What are your thoughts about the integration of PACT with H2H and whether or not there are redundant processes competing for resources?” 

Dr. Paul Heidenreich:Well, personally I don’t necessarily see them competing. Because the H2H is a goal for the facility and I think some have actually done this within the PACT system. And it could very well be that the PACT says yes we agree with these goals and working on these at the time of transition of care and so I don’t think they necessarily need to compete. I think in the past, something like H2H often had a specialty focus because those are often the champions. When the facility is interested in reducing heart failure readmission rates, it’s often a specialty person who is the most passionate about that. But that doesn’t have to be the case, it could easily be that the PACTs would be the ones to implement the three aims of H2H. 

Moderator:Thank you. We do have a few more questions that have come in: “How do we address the elephant in the room, meaning lack of support from leadership at the majority of facilities?” 

Dr. Paul Heidenreich:I think that’s a very good point. I will say in defense of the facilities, or leadership, that they’re getting a large number of requests for resources and they need to decide among these what is most likely to benefit or impact the care at the VA, particularly impact performance measures. And though they may potentially rightly be a little skeptical to say “Well I’m not sure you’re going to reduce the readmission rate”, this is important to them because it is publicly reported, although not a performance measure. The VA does publicly report it alongside Hospital Compare with other non-VA facilities. So while they have an interest they potentially could have said “Well I want more data before I give you a lot of resources.” So I think on the one hand yes any project is going to need more resources for it to be completely successful. On the other hand I think we need to be able to show in some way, that yes this project is effective, can be effective with some real data to really get the buy-in of the senior leadership. 

Dr. Anju Sahay:So this is Anju, Molly can you hear me? 

Moderator:Yes, you are coming through.    

Dr. Anju Sahay:So I do want to add a couple of things that, while Paul is talking about this data at the facility and we did share that. We provided a toolkit in Phase I, where we were working only with the intervention facilities. We had a couple of.. we launched this, H2H had introductory webinars and emails providing them information and then after three months, we followed up with facilities and worked with the early adopters, facilities which had initiated the projects – already the VA H2H projects. And we planned two webinars where they presented the projects and discussed the barriers and facilitators which they dealt with and strategies and lessons learned. And they shared that information with all the other members from other facilities, which was really helpful to them.     

And as part of it, we also sent them a toolkit which was thirty day readmission and mortality rates for their facility, and the national VA. And we sent a memo with talking points which they could discuss with the local leadership. We also had data for each of the facilities which we gathered a little earlier in terms of the current heart failure practices and processes. So you know we provided them all this data as a toolkit so they could see where they are versus the national VA and information which they could take to the local leadership. So that was very helpful to them. 

Moderator:Thank you for that reply. The next question: “You did talk a little bit about costs. But what was the cost of the evaluation of H2H implementation as compared to the control group?” 

Dr. Paul Heidenreich:Well again, the main thing we know and can potentially calculate out a cost is about that 19 hours per week were being used for H2H projects. So if we want to say for those that start, that did an H2H project, they were on average spending about 19 hours per week among all staff they set on that project. Now, we didn’t try to do a .. we weren’t able to do a control versus non-control because we didn’t ... ideally we’d probably need to measure all activity of all staff and what they’re doing. So we really just said, of those who are doing H2H projects, how much are you spending time on? And it’s very imprecise, because you know we realize that it’s a very fuzzy number. You know the facilities and the person filling that out may not have complete knowledge of all that’s going on. And there’s no .. there’s probably no good tracking at their facility of those hours since most of those things probably are not being paid for separately. So it’s very difficult to come up with a number but I think that 19 hours is the best that we have.  

Moderator:Thank you. And our final question: “With JCAHO looking at top performers in the heart failure measures, why did less than eighteen facilities make these measures?” 

Dr. Paul Heidenreich:I guess I’m not quite clear on that question. 

Moderator:We can ask the person writing in to clarify a little bit better. While we’re waiting for them, do you or Anju having any concluding comments you’d like to make? 

Brian: Molly, if you can hear me I think the question is .. 

Moderator:Go ahead Brian.      

Brian:Given the Joint Commission pressure, which presumably would cause many facilities to comply, why were the rates relatively low? 

Dr. Paul Heidenreich:The rates of.. I guess the rates of what? That’s the question. 

Brian:Molly could you read it again? 

Moderator:Yes. With the .. I guess its Joint Commission, the JCAHO, looking at top performer in the HF measures, why did less than eighteen facilities make these measures? 

Dr. Paul Heidenreich: Yeah I’m not sure. The four Joint Commission measures in general, that were well over 90% of patients meeting those. So those are very high. So I’m not sure what the other Joint Commission measures to which the person’s referring. 

Moderator:All right, not a problem. Well they are not writing in to further clarify. So why don’t you go ahead with your concluding comments. 

Dr. Paul Heidenreich:Okay. 

Dr. Anju Sahay:We’d like to thank the QUERI programs providing the service directed project funding for this project. 

Dr. Paul Heidenreich:   Yes and I wanted to thank Anju and say I think it does show the importance of evaluating such a project that the VA has agreed to take on. 

Moderator:Excellent, I want to thank you both for sharing your study and your expertise with the field and I want to thank our audience for joining us today. This .. you can join us for the next QUERI implementation research cyber seminar, that will take place also with Dr. Heidenreich and Sahay on November 8th, at 3:00 p.m. Eastern and that will be Heart Failure Network of VA Providers: An Innovative Strategy for Implementation of Evidence Based Practices. So to register for that session, please go to the HSR&D home page and then from there on the left navigation bar you can find the cyber seminar catalog. So thank you once again to our presenters and our attendees and please do fill out the feedback survey that will load on your screen as you exit today’s session. Thank you very much, have a nice day. 

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