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.

Physician champions can help health systems and hospitals overcome challenges associated with changing supply items.

Changing devices, implants, and other products is challenging to hospital supply chain functions—often causing resistance from clinicians wedded to existing supply items.

That is why health systems and hospitals can drive change and value in their supply chains with the help of physician champions. And one system is doing just that.

Kettering Health Network is tapping the clinical expertise of physicians to tackle these predicaments. Trisha Gillum, director of supply chain management at the Dayton, Ohio­­­–based health system, says physicians can play diverse roles in supply chain.

"It can be as small as a physician champion on a single project, to being a physician champion for a service line, to being on the payroll for supply chain," she says.

Here are three reasons to enlist physician champions to improve your supply chain.

1. Physician champions actively engage in supply chain projects
 

Gillum says the best physician champions for medical supply changes are personally engaged in the effort. "They are willing to understand both the financial and the clinical nuances to a project. They are also willing to speak with their peers—to be a cheerleader or champion for a project."

When Kettering identifies engaged and respected physicians who are interested in serving in the champion role, the doctors receive training from The Advisory Board Company. Physician champion programs at this Washington, D.C.–based consultancy range from individual sessions to a physician leadership track that has sessions held over several months.

Two primary elements of the education programs are business instruction and learning about the nuances of the changing healthcare industry.

"Many physicians are not in tune with everything that is going on in the hospital environment," Gillum says. "They don't understand when we say we need to save money. So, there is education about financial pressures and clinical pressures."

Another educational goal is giving physicians leadership skills, she says.

"We are asking them to step out of their traditional roles and communicate with their peers at an advocacy level. To do that, we not only need to provide the data to support product conversations, but also give them the tools necessary to have those conversations."

2. Physician champions contribute valuable input into supply choices
 

Physician champions play a potentially decisive role in proposed supply changes, Gillum says.

"If you really want a physician to get engaged, they will bring their own mindset about what the answers should be. You cannot expect a physician to come onboard and rubberstamp the process," she says.

Supply chain managers and other leaders should be open to opposing views from physician champions, she says. "They are going to want to engage in the process. They are going to want to modify it. So, you may end up in an entirely different place than you expected."

When physician champions object to proposed supply changes, open communication is essential, Gillum says.

"You have to be transparent. You can't ask a physician to own something like a cost-savings initiative unless you are willing to say how much we are going to make on a procedure. You have to be willing to share all of the data and to give physician champions all the facts to make intelligent decisions," she says.

Supply chain managers should treat physician champions as valued teammates, Gillum says. "You have to realize that you have asked physicians to play a supply chain role and to provide information. If you disregard what they are saying, you are going to lose partners."

The best-case scenario for physician champions is when they take ownership of a supply change project, she says.

"I had a physician who went out and talked with every one of his peers who performed a particular procedure. He convinced every one of them that we needed to make a change. He was able to accomplish more in those conversations than I could have accomplished in months of conversations with the same group of physicians," she says.

3. Physician-champions help decide supply changes that impact patients
 

Health systems and hospitals benefit from physician champion participation in supply chain, and the clinicians benefit as well.

Gillum says the two primary benefits for clinicians who assume physician champion roles are gaining experience that helps them compete for hospital administration jobs and helping to decide supply changes that could impact their patients.

"I had one physician say he was passionate about the supplies he used on his patients. The best way physicians can control the supplies that they get is to be part of the conversation and part of the decision," she says.

National data indicates the Hospital Readmissions Reduction Program is having a positive impact on patients under 65 as well as patients with Medicaid and private insurance coverage.

Medicare's Hospital Readmissions Reduction Program (HRRP) is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative, recent research shows.

"There appears to be a systematic improvement in readmission rates for patient groups beyond the population of fee-for-service, older, Medicare beneficiaries included in the HRRP," researchers wrote this month in the American Journal of Medicine.

The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.

In 2012, the Centers for Medicare & Medicaid Services started financial penalties for high readmission rates for three conditions: acute myocardial infarction (AMI), heart failure and pneumonia. Under HRRP, hospitals are penalized if they have higher than expected risk-standardized readmission rates.

The American Journal of Medicine researchers examined data from the Healthcare Cost and Utilization Project's Nationwide Readmissions Database (NRD), a nationally representative all-payer database. They focused on readmission rates across six age-insurance groups for the three HRRP targeted conditions as well as conditions not targeted by HRRP. The data features nearly 60 million hospitalizations and more than 18 million readmissions.

The six age-insurance groups were patients over 65 with Medicare, Medicaid, or private insurance; and patients younger than 65 with Medicare, Medicaid, or private insurance.

Broad readmission gains
 

The NRD data shows reductions in readmissions rates across all six age-insurance groups.

• Readmissions for AMI patients over 65 declined significantly for all three forms of healthcare coverage: the readmission rate for patients with Medicare coverage dropped from 19.2% in 2010 to 15.5% in 2015; for the privately insured, the readmission rate dropped from 14.6% to 12.4%; and for patients with Medicaid coverage the readmission rate dropped from 23.4% to 18.3%.
   
• Readmissions for AMI patients under 65 also declined significantly: decreased readmission rates for privately insured and Medicaid patients mirrored the lower readmission rates for patients over 65. Medicare patients under 65 experienced a modest decrease in readmission rates from 19.7% to 18.6%.
   
• Similar to AMI, readmission rates for heart failure decreased significantly for all six age-insurance groups.
   
• Readmission rates for pneumonia decreased for all six age-insurance groups, but the decline was significantly larger for patients over 65 compared to those under 65.
   
• For conditions not targeted under HRRP, there was a small decrease in readmission rates in most age-insurance groups. For example, among Medicare patients over 65, readmission rates dropped from 16.3% in 2010 to 15.5% in 2015; but among the privately insured, readmission rates dropped from 14.0% in 2010 to 13.5% in 2013, then rose to 13.8% in 2015.

Systematic changes
 

The data collected in the American Journal of Medicine study indicate HRRP is having a widespread impact on hospital readmissions, the researchers wrote.

"From 2010-2015, 30-day all-cause readmission rates for acute myocardial infarction, heart failure, and pneumonia declined across all age-insurance groups. Readmission rates decreased modestly for conditions not targeted by the HRRP in all age-payer groups, with larger declines among Medicare patients aged ≥65 years," they wrote.

This finding implies hospitals have made extensive changes to clinical care rather than changes targeted only at HRRP-impacted patients, the researchers wrote.

"These patterns are consistent with the hypothesis that implementation of the HRRP was associated with systematic changes in the care of patients and reduced readmission risk beyond the HRRP's target population of fee-for-service Medicare beneficiaries."

If you are going to change your discharge model for at-risk geriatric patients, there are four elements you are going to need.

Geriatric inpatient care and the transition of patients to postacute care are among the most daunting challenges for health systems and hospitals because of the possibility of patient functionality losses in the inpatient setting and costly readmissions after discharge.

In one effort to rise to these challenges, Philadelphia-based Penn Medicine has launched Supporting Older Adults at Risk, or SOAR. SOAR which served its first patient in January, is modeled after the "flipped" discharge program crafted at Sheffield Teaching Hospitals in the United Kingdom.

Penn Medicine has modified the U.K. approach to "flipped" discharge, which features in-home patient assessments after hospital discharge more prominently than in-hospital assessments at discharge, says Rebecca Trotta, PhD, RN, director, nursing research and science, at the Hospital of the University of Pennsylvania in Philadelphia.

"We tried to adhere to the central tenets of flipped discharge: maintaining a geriatric focus; having comprehensive services, not just medical services; and offering services early and intensively," she says.

SOAR has served 46 patients so far, and the early data is promising, Trotta says. A primary goal of the initiative is decreasing hospital length of stay, which has dropped about 1.5 days for SOAR patients.

Lowering length of stay reduces risks associated with hospital care, she says. "We are thinking about how we can maximize care in the home setting because we know when patients are in the hospital they are at higher risk for falls, functional decline, and delirium."

Flipping the discharge model at Penn Medicine means equipping its SOAR program with the following four elements:

1. Geriatric nurse consultants
 

Four nurses who serve as geriatric nurse consultants in the inpatient setting are a building block of the SOAR initiative. They are staffed through the department of nursing.

"Their full-time job is to identify older adults upon admission who could benefit from a comprehensive geriatric assessment, to share recommendations and findings with the interprofessional team, to follow up on those recommendations, and to collaborate with caregivers," Trotta says.

The geriatric nurse consultants establish working relationships with patients that underpin the SOAR program, says David Resnick, MEd, MPH, innovation manager for the Acceleration Lab at the Penn Medicine Center for Health Care Innovation in Philadelphia.

"The geriatric nurse consultants spend a lot of time with patients in the hospital conducting assessments and getting to know them and their caregivers, which builds trust. So, we have seen refusals of home care at the door—which happen about 15% of the time with traditional home care—fall to zero with SOAR," he says.

2. Home assessments
 

SOAR provides home health services through Penn Care at Home, a division of Penn Medicine. When patients return home, a Penn Care at Home staff member conducts an assessment.

The home assessments confirm or revise discharge assessments conducted in the hospital including physical therapy and occupational therapy evaluations, she says. "SOAR verifies what is needed. We often find patients need more or different things than we thought in the hospital."

Home assessments help recovering patients to live at home, Trotta says.

"The goal for our older patients is to maximize their ability to take care of themselves, which includes their daily living and functioning. They need to do things like get to the bathroom, prepare food, do laundry, and keep their house clean. Seeing how that unfolds in their real environment lets us see where they might need help versus seeing it in the hospital," she says.

3. Rigorous handoff
 

"We do a handoff call with the geriatric nursing consultants that includes highlighting key things they have learned about the family and caregivers. They also work on medication reconciliation jointly with the home care team," Resnick says.

Hospital staff and the home care team work together closely for the first 48 hours after a patient has been discharged, he says.

"For the first two days that a patient is home, the home care team is tethered back to the hospital. The home care team can either call or message the acute care provider and talk with the geriatric nurse consultants for issues that arise in the home such as medication discrepancies and other concerns. They are not on their own," he says.

4. Intensive services
 

SOAR provides a level of service that is more extensive than traditional home healthcare, Trotta says.

"It is organized differently than standard home care. Typically, across the country the average time to the first home visit is at least two to three days. For an older person leaving a hospital without a connection to their next provider for two or three days, there is a risk of something going wrong in that time," she says.

With SOAR, patients get a same-day visit after discharge. They leave the hospital in the morning, then see a home care nurse that afternoon. They also see that same nurse the next day.

Same-day and next-day visits following hospital discharge allow home care team members to address immediate needs such as questions about medications and usage of durable medical equipment, Trotta says. "There is more immediate attention as patients transition from the hospital to the home."

SOAR provides a level of services, which are reimbursable by Medicare and commercial insurance, that is often not included in traditional home care, she says.

"Our patients are defaulted to receive physical therapy, occupational therapy, and social work. In traditional home care, those services can be delayed or not recognized as needed at all," Trotta says.