Best Practice Submission
Congestive Heart Failure Readmission Strategies
Point of Contact: Sam Spencer, (210)297-1044, SJSPENCER@baptisthealthsystem.com
Catherine Ortega, (210)297-7397, CLORTEGA@baptisthealthsystem.com
Group Involved with the Project. The Baptist Health System’s Regional Cardiovascular
Department and the Baptist Medical Center Nurse Navigator
Submitted by Major Seth Thomas French IV
11 May 2012
Executive Summary: With the elevated trend in Chronic Heart Failure readmission (CHF)
rates, the Centers for Medicare and Medicaid Services (CMS), under the Patient Protection and
Healthcare Reform Act, passed legislation in March 2010 that introduces a pay for performance
methodology that focuses on penalizing hospitals with higher than expected readmission rates
starting fiscal year 2013. The Baptist Health System, understanding the financial impact of this
legislation, instituted a CHF case management team with case managers to focus on improving
readmission rates, patient adherence to discharge notes, and monitoring reimbursement from
CMS.
Objective of the Best Practice: Implement a CHF case management team to evaluate, trend and
develop strategies to improve CHF readmission rates. The objective is to utilize case managers to
influence CHF core measure outcomes through proactive methodologies to care management and
educating CHF patients to maximum health and effective self-care. Additionally, case managers will
strive for a seamless transition across all levels and locations of health care, to include downstream
providers, to ensure an efficient continuum of care. With the information provided by the case
management team, executives, clinical directors, physicians, and patients will be provided evidence-
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based data, which will enhance clinical outcomes and maximize acute care reimbursements from
CMS.
Background: CHF is also a local issue. Dr. Fernando Guerra noted health inequalities in Bexar
County, by citing “16 percent of deaths occur from heart disease among non-Hispanic whites, 30
percent of blacks and 23 percent of Hispanics” (Finley, 2010). It is important to note that San
Antonio is the seventh largest city in the United States with 1,300,000 residents, sixty three percent
of whom are Hispanic in 2006 (Demographic, 2010). Statistically, Hispanics encounter numerous
barriers to health care related to “socioeconomic, linguistic, and cultural factors”, have “novel
metabolic risk factors for CHF”, and are projected to become a majority population, caring for CHF
patients (Vivo, Krim, Cevik, & Witteles, 2009, p 1168). CHF readmissions inside of 30 days
regularly occur, are expensive, and are sometimes life-threatening which is normally associated with
patient unawareness and gaps in follow-up care. In 2010, to address these inefficiencies, the Baptist
Health System (BHS), a five acute-care hospital system in San Antonio, implemented a CHF case
management team to assess and improve upon CHF readmission rates.
Literature Review: Internationally, fifteen million people have symptoms of CHF (Young, 2004).
Approximately 5.8 million people in the United States (U.S.) have CHF and about 670,000 newly
diagnosed cases are reported yearly (Lloyd-Jones, Adams, Brown et al, 2010) (as cited in CDC HF
Facts Sheet, 2010). In patients requiring hospitalization age 65 and older, CHF is the number one
reason for admission (NHLBI, 2011). In 2001, there were “over 500,000 hospital admissions
primarily for CHF in women and over 400,000 in men”, up from 200,000 in 1970 (Young, 2004).
With the forty percent of readmissions being voidable, and one in four Medicare CHF patients being
readmitted within a month, the goals of Healthy People 2020 includes a reduction in hospitalization
of older adults with heart failure as the principal diagnosis (Healthy People 2020 Heart Disease &
Stroke, 2011).
American Heart Association (AHA) data from 2008 reported a yearly CHF prevalence rate of 2.1
percent in Hispanic men and 1.9 percent in Hispanic women, 2.8 percent in non-Hispanic white
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males and 2.1 percent non-Hispanic white females, and 2.7 in non-Hispanic black men and 3.3
percent in non-Hispanic women of African American background (Vivo, Krim, Cevik & Witteles,
2009). The National Heart Lung and Blood Institute (NHLBI) data indicate 400,000 new cases of
CHF annually (NHLBI, 2011). Taking in to account an aging population in the U.S., the frequency of
CHF is estimated to increase to nearly six million people by 2030 (Young, 2004). In the U.S., heart
disease is the primary cause of death in Hispanics, white-non Hispanics and black non-Hispanics in
ages sixty five and older (Healthy People 2020 Closer Look: Disparities, 2011). According to the
CDC, “about one in five people who have heart failure die within one year from diagnosis” (LloydJones, Adams, Brown et al, 2010) (as cited in CDC Heart Failure (HF) Facts Sheet, 2010). The
National Heart Lung and Blood Institute data demonstrates a five year mortality rate of fifty percent
for CHF (NHLBI, 2011).
Young estimates the cost of every HF hospital admission to cost between $6000 and $12,000 in the
U.S. (Young, 2004). In 2009, the approximate cost of treating HF in the U.S. was $37.2 billion, as
illustrated in Table 1 (Lloyd-Jones, Adams, Brown, et al, 2010). The cost of CHF, including “health
care services, medications, and lost productivity” reached $39.2 billion in 2010 (CDC HF Fact Sheet,
2010).
Implementation Methods: Starting in May of 2010, disease management, the patient-centered
approach, and communication were all methods used by case managers and physicians to enhance
the health of Baptist’s CHF population. The use of bilingual individualized patient education on
diagnosis, signs & symptoms, activity, sodium restriction, weight monitoring, and actions to take if
CHF worsens i.e. referral to nutrition, home health care, and cardiac rehabilitation if warranted, as
well as bi-weekly phone follow-ups for one month were all used. Additionally, case managers
aggressively collaborated with downstream providers, such as skilled nursing facilities to provide
individualized patient treatment plans.
Results: To trend the percentage of encounters for patient’s that had a discharge diagnosis of heart
failure and were readmitted within 30 days as a non-elective acute care inpatient, a report was
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queried from Midas + DataVision (statistical reporting tool) where the index encounters in the
denominator population where compared to the numerator report (which is a qualifying readmission
encounter).
In analyzing the trending data, starting in Fiscal Year 2008, it sustained ~15%
readmission rates through 2010; however, in FY 2011 through the case management teams efforts,
the percentage of readmission rates dropped to 12.45%. Not only did the CHF readmission rates
decline, the number of CHF patients admitted within BHS CHF population declined as well. See
Table 1 for a summation of the BHS turnover rates from 2008-present.
Conclusion: Undoubtedly, readmission of CHF patients within 30 days is a pervasive problem that
adversely affects patients, payers, and providers.
Through Baptist’s proactive approach of
establishing a case management team with case managers that focused on the patient-centered
approach, disease management, care coordination, and transitional management a significant
improvement was noticed since the programs inception. With CMS passing legislation that will
penalize health care systems with excessive readmission rates starting FY13, it is necessary for
hospitals to calculate their CHF 30 day readmission rates and implement an action plan that will
influence their bottom line while improving the healthcare of their CHF patients within their market.
Table 1.
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Heart Failure
(Lloyd-Jones, Adams, Carnethon, De Simone et al, 2008)
Table 2.
CHF % Readmits within 30 Days, Age > 64
Indicator: CHF % Readmits within 30 Days, Age > 64
Fiscal Year
Numerator Denominator % Readmissions
2008
223
1476
15.11%
2009
227
1464
15.51%
2010
204
1335
15.28%
2011
145
1165
12.45%
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References
Centers for Disease Control and Prevention(CDC). (2010). Heart Failure Fact Sheet. Retrieved
from http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_failure.htm
Demographic information. (2010). City of San Antonio: Planning & Development Services
Department. Retrieved January 25, 2011from
http://www.sanantonio.gov/planning/GIS/demo_info.asp
Finley, D. (2010, September 26). Fewer in Bexar County dying from heart attacks. San Antonio
Express News. Retrieved from
http://www.mysanantonio.com/news/local_news/article/Fewer-in-Bexar-dying-from-heartattacks-675000.php
Healthy People 2020. (2011). Table 1. Closer Look: Health Disparities Compare the Top 10
Causes of Death across Populations. Retrieved from
http://www.healthypeople.gov/2020/chart.aspx?raceId=5&ageId=15&genderId=3&race=His
panic&age=65+years+and+over&gender=Both
Healthy People 2020. (2011). 2020 topics and objectives: heart disease and stroke. Retrieved
from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=21
Lloyd-Jones D, Adams RJ, Brown TM, et al. (2010). Heart disease and stroke statistics-2010
update. Circulation, (121),e1-e170. doi: 10.1161/CIRCULATIONAHA.108.191261.
NHLBI Congestive Heart Failure Data Fact Sheet. (2011). National Heart Lung & Blood
Institute. Retrieved from
http://www.wrongdiagnosis.com/c/congestive_heart_failure/prevalence.htm
Vivo, R., Krim, S., Cevik, C., Witteles, R. (2009). Heart failure in Hispanics. Journal of the
American College of Cardiology, (53), 1167-1175 doi:10.1016/j.jacc.2008.12.037
Young, J. (2004). The global epidemiology of heart failure. The Medical Clinics of North
America, (88), 1135-1143.
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