Front-loaded Home Care and Office Visits May Reduce Heart Failure Readmissions

A new study finds that front-loaded home care combined with physician office visits shows promise in reducing HF readmissions.

For years, hospitals and researchers have been searching for the right combination of care needed to prevent the readmission of heart failure patients. Still, a 2015 study found that only one in 70 hospitals has been able to bring the readmission rate for these complex patients below 20%. 

With penalties for readmissions rising, the search is still on. Options include better discharge planning, implantable pulmonary artery pressure monitors, and early, intensive home health care—often described as "front-loaded" care. 

And while better home health makes intuitive sense, its impact on readmissions has not been well-studied. Which is why researchers from the Center for Home Care Policy and Research in New York City decided to look specifically at heart failure readmissions of patient receiving follow-up home health care. They compared three interventions: early, intensive home health nursing; physician follow-up within a week; and a combination of the two.

The findings, published in the journal Health Services Research, suggest that neither intervention has much impact alone. But, the combination of a visit to the doctor and multiple home nursing visits in the week following discharge reduced the probability of readmission by roughly eight percentage points. That's a drop from approximately 20% of patients to roughly 12%. (However, the researchers note that the percent reduction could fall into a range between 4.1 to 12.3 points.)

The study validates the benefits of a specific approach to front-loaded care, said lead researcher Christopher Murtaugh, Associate Director, VNSNY Center for Home Care Policy and Research.

"There is very little research evidence to support [front-loaded care] despite the fact that the industry feels that it is likely to be important," he said.

His team consulted with providers for help defining early intervention and physician follow-up. They then used data from more than 98,000 Medicare heart failure patients who were discharged from hospitals to home care. Of the sample, 40.1% received neither treatment, 23.0% received only nursing care, 24.3% physician care only, and 12.6% both home health and physician care.

The adoption of the combination of treatments is dependent on "timely action during the hospital stay," according to the study. The findings call for "closer coordination between medical and home health providers in the clinical management of HF patients immediately after hospital discharge." Often, that is not the case, Murtaugh said.

"The information that is actually available to the home health agency is very scanty," he said, sometimes no more than the patient's name and discharge date.

"The agency needs to follow up and make sure they get all the clinical information," Murtaugh said. "But, historically, the [hospital's] practice has not been to give the home care agency rapid, timely complete clinical information about a patient."

Efforts by the Centers for Medicare & Medicaid Services recognize the need for better post-acute care coordination, he said.

Adrian Hernandez, MD, is a cardiologist and director of health services and outcomes research at the Duke University Medical Center Clinical Research Institute. His team has looked at heart failure and readmissions.

"There will need to be a multi-modal approach towards preventing readmission," he wrote in an email after reviewing the study: "There isn't a silver bullet and we will need engagement from different perspectives. More integration of care with new models that go from hospital to home and back may be very helpful. Having more continuous engagement and disease management can help optimize care and provide better pathways for patients if or when they get worse."