Improving Heart Failure
Management in Skilled Nursing
Facilities
AMDA Foundation/Pfizer Quality
Improvement Award
Rebecca S. Boxer, MD
Assistant Professor of Medicine
Heart Failure is the Most Common Reason for
30-Day Rehospitalization
Jencks N Engl J Med 2009
Per 1,000 Person Years
Hospital Discharges for Heart Failure by Age and Sex
50
43.0
40
30.7
30
22.3
20
14.8
9.2
10
4.7
0
65-74
75-84
85-94
Age
Men
Women
(FHS: 1980-2003). Source: NHLBI.
* HF based on physician review of medical records and strict
diagnostic criteria.
Discharge Status from the National Hospital
Discharge Survey 1980-2004
70
60
50
Home
Other ST
LTC*
AMA
Death
Unknown
% 40
30
20
10
0
19801984
19851989
19901994
*LTC includes NH and SNF
19951999
20002004
Fang JACC 2008;52:428–34
Hospital to Home
(does not include SNF)
A national quality improvement initiative
of the American College of Cardiology
and the Institute for Healthcare
Improvement
Goal
Reduce 30 day, all-cause readmission
rates for patients discharged with cardiac
conditions by 20 percent by December
2012.
The Bridge Project
• Assess the HF Management in 4 SNF in
Greater Cleveland area
And then
• Identify needs of SNF
• Create HF disease management program
for SNF
Results from 4 Facilities
•
•
•
•
•
No HF disease management programs
No tracking of patients with HF
Inadequate dietary flexibility
Poor symptom recognition
No medication titration protocols or flexible
diuretic regimens
Boxer et. al. JAMDA 2011 in press
AMDA Foundation/Pfizer Quality
Improvement Award
Preparing the SNF for change in HF Management
• Program to Educate all Staff
• Train the Trainer
• Develop multi-media tools to teach both
staff and patients
Results from HF Educational Program
dvanced Curricula
Advanced
Pretest
Posttest
p-value*
Knowledge mean score (n) 82.8%(57) 96.2%(26)
<.01
Confidence mean (n)
3.99(30)
4.69(20)
<.001
Pretest
Posttest
p-value*
Basic
Knowledge mean score (n) 82.6%(54) 95.7%(46)
<.001
Confidence mean (n)
.055
3.46(46)
4.87(43)
Boxer et. al. JAMDA 2011 in press
Development of HF Teaching
Videos
1. Nurse teaching STNA to manage HF
2. STNA teaching Patient to manage HF
3. Nurse teaching family to manage HF
- Focus Group Assessment – Motivational
Interviewing Techniques added
STNA = State Tested Nurses Aide
The Bridge Project a Collaboration
Thanks to:
• Ileana Piña MD, MPH
• Mary Dolansky RN, PhD
• Jeanne Hitch Med, MA
• Peter Degolia MD
• Matthew Wayne MD
• Megan Frantz, BA
• Regina Prosser RN-BNC
• AMDA Foundation/Pfizer
Quality Improvement
Award
• The McGregor
Foundation
• CWRU/Mt Sinai Skills
and Simulation Center
• Case/Cleveland Clinic
Multidisciplinary Clinical
Research Training
Program; 1KL2RR024990