10 Approaches to Reduce Readmissions for Heart Failure and COPD

Patients with both heart failure and chronic obstructive pulmonary disease have a high cost of care, but there are multiple strategies to limit readmissions.

Improving clinical management of patients with both heart failure (HF) and chronic obstructive pulmonary disease (COPD) can lower cost of care, research published this month shows.

Readmissions are among the most prominent areas to reduce cost of care. Earlier research found that a regional general hospital experienced negative total margins in both COPD and HF, costs that could have been avoided by limiting readmissions.

Healthcare clinical leaders who seize opportunities to limit readmissions not only lower cost of care, but can also boost quality of life for patients and avoid financial penalties under the Hospital Readmissions Reduction Program for HF.

"Patients with both COPD and HF pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies," researchers wrote this month in the journal CHEST.

The CHEST researchers focus on 10 approaches to reduce readmissions for patients with both HF and COPD that your health system can adopt.

1. Make accurate diagnoses
 

Particularly for COPD, hospitalization is often the first opportunity for accurate diagnosis, the researchers wrote.

"Hospitalization for an acute exacerbation often represents the first time COPD is diagnosed in an individual patient. This may be attributed to the fact that spirometry is underused in outpatient settings to establish the diagnosis of COPD," they wrote.

Several tests, including echocardiography, can diagnosis HF in COPD patients.

"Because spirometry is not thought to be accurate during acute HF exacerbation, anatomic assessment of lung parenchyma with CT scan may offer valuable adjunctive information at reasonably high sensitivity and specificity. In addition, chest CT scan may offer valuable ancillary information regarding right heart size,

the diameter of the pulmonary artery, and the presence of coronary calcification," the researchers wrote.

2. Strive for early detection of exacerbations
 

To reduce readmissions, early detection of patients with both COPD and HF is helpful for two reasons, the researchers wrote.

First, specialists can be involved quicker, which allows for faster determinations about root causes of patients' COPD or HF. Specialist involvement also quickens development of treatment plans.

"Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow up appointment scheduling, and coordination of home services. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization," the researchers wrote.

Early detection of exacerbations can also allow care teams to perform risk stratification, particularly for HF, they wrote. "It may be possible to identify the 20% to 30% of the population who are at low risk for readmission. These patients, if identified early, may be good candidates for observation care and may not need intensive services."

3. Ensure specialist management in the hospital
 

Specialists not only maximize the quality of inpatient care but also can play a key role at the time of discharge, the researchers wrote. "Because specialists are often tasked with the outpatient follow-up of HF and COPD, specialist involvement while in hospital allows for treatment plans to be created in continuity with those that will be effected as an outpatient."

4. Address root causes
 

HF has several correctable root causes, the researchers wrote. "Identification of and treatment of occult ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable."

Addressing root causes of COPD is more difficult, they wrote. "Regarding COPD, particularly in younger patients or patients in whom exposure to cigarette smoke has not been high, consideration should be given to … referral for evaluation for lung volume reduction surgery or lung transplantation."

5. Use evidence-based therapies
 

"Medical therapies improve outcomes for both HF and COPD. These should be initiated in hospital where feasible because initiation of therapy while in hospital or soon after discharge likely translates into improved rates of outpatient therapy," the researchers wrote.

For HF, several kinds of medications have shown effectiveness such as beta-blockers, angiotensin receptor blockers, and aldosterone antagonists. "Not only are there long-term outcome benefits for these therapies, evidence suggests early

initiation of HF therapies can reduce 30-day readmissions," the researchers wrote.

There are fewer evidence-based therapies linked to reduced readmissions for  COPD, but earlier research has shown that noninvasive positive pressure ventilation reduces readmission at 28 days compared with oxygen alone.

6. Engage patients in their care
 

Enlisting HF and COPD patients as active participants in care and monitoring exacerbations is essential, the researchers wrote.

"Many strategies for engaging patients in care have been tested, including teach to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful. Patient activation strategies focus on developing critical health behaviors in patients that can engender better health," they wrote.

7. Establish feedback loops
 

Creating mechanisms for care plan course corrections is critical to outpatient success, the researchers wrote.

"Feedback loops can allow for clinical stabilization before rehospitalization is necessary. Self-care plans for both COPD and HF have been found to be effective. Nurse-led telephone follow-up for COPD and HF at 48 to 72 hours may also help support patients post-discharge."

8. Schedule follow-up appointments
 

Before hospital discharge, a follow-up appointment should be established with an advanced practice provider or nurse with pharmacist support.

"The purpose of early follow-up is (1) to identify and address gaps in the discharge plan of care, (2) to retailor the discharge plan of care to better suit the patient in the outpatient environment, (3) to reinforce critical health behaviors, and (4) to advance the plan of care, time permitting," the researchers wrote.

9. Address other comorbidities
 

Multiple comorbidities such as septicemia and renal dysfunction are common for patients with COPD and HF, the researchers wrote.

"This underscores the need for involvement of the primary care physician for assistance in managing comorbidities. In a study evaluating process of care metrics associated with better outcomes in patients hospitalized with HF,

partnering with community physicians and arranging to send discharge summaries to the primary physician were among the strategies most associated with lower readmission risk."

10. Arrange home health services
 

For HF patients, home services such as physical therapy, patient education, and medication instruction have been associated with reduced readmission rates at three to six months. Telehealth has shown effectiveness in managing COPD.