UCSF Heart Failure Program: Improving Outcomes

reprinted from Issue 14, Spring 2012 of Frontiers of Medicine (PDF)

Heart failure program coordinators Maureen Carroll, RN, CHFN (center), and Eileen Brinker, RN, MSN, with UCSF Medical Center patient Alethea Travis. Carroll and Brinker are part of a new team effort to reduce preventable readmissions among heart failure patients.



Improved care of elderly patients with heart failure has led to shorter hospital stays and lower rates of death while in the hospital. Unfortunately, after leaving the hospital, many of these patients are at risk of being admitted to a nursing home, are frequently re-admitted to the hospital, or die in the month following hospital discharge. Working with a multidisciplinary team, UCSF Medical Center has been able to care for more patients in their homes, prevent hospital readmissions and provide palliative care for those with late-stage heart failure.

Heart failure affects about 5 million Americans, and is the leading cause of 30-day hospital readmissions among older patients. It is a chronic, progressive disease in which the heart is unable to pump enough blood to the rest of the body, causing fatigue, shortness of breath and swelling in the feet and legs. Patients often take multiple medications to manage their illness, must restrict their salt intake, and need to weigh themselves daily to detect whether they are retaining excess fluid, which can back up into their lungs. Yet despite the complexity of the disease, some studies have estimated that up to half of heart failure readmissions are potentially preventable.

In 2006, 23 percent of heart failure patients age 65 and older were readmitted to UCSF Medical Center within a month of discharge, whereas by 2011, only 12 percent were readmitted. (The national average is 25 percent.) The rate of heart failure patients readmitted to the hospital within 90 days also dropped, from 45 percent in 2006 to 27 percent in 2011 – a 40 percent reduction.

“Each hospital readmission has a story, and we try to find out what it is,” says Eileen Brinker, RN, MSN, program coordinator for a recently established heart failure readmission initiative at UCSF. “Were they able to get their medications? Are they unable to get to appointments because they can’t get down the stairs? Is the patient’s caregiver burned out?”

Brinker and her fellow program coordinator, Maureen Carroll, RN, CHFN, are at the center of UCSF’s successful efforts to provide better care to older heart failure patients. By cultivating excellent communication, patient education, team approaches to care and careful attention to transitions between hospital and home, the program has reduced 30-day readmissions for heart failure patients 65 and older by nearly half compared to five years ago.

In 2006, 23 percent of heart failure patients age 65 and older were readmitted to UCSF Medical Center within a month of discharge, whereas by 2011, only 12 percent were readmitted. (The national average is 25 percent.) The rate of heart failure patients readmitted to the hospital within 90 days also dropped, from 45 percent in 2006 to 27 percent in 2011 – a 40 percent reduction.

“Our team takes ownership of the patient, like they’re part of our family. Our goals are to reduce hospitalization, help patients feel better and do more to slow progression of their disease, and improve longevity.”

– Teresa De Marco, MD, director of the Heart Failure and Pulmonary Hypertension Program

Building a Team

“Creating teams that look at the whole patient is part of becoming accountable for the continuum of care,” says Teresa De Marco, MD, director of the Heart Failure Program at UCSF, and a physician champion of the heart failure readmission reduction initiative. “Our team takes ownership of the patient, like they’re part of our family. We want to make sure they do well, not just when they are in the hospital, but after they are discharged. Our goals are to reduce hospitalization, help patients feel better and do more to slow progression of their disease, and improve longevity.”

The heart failure readmission reduction project was established in 2008, with funding from the Gordon and Betty Moore Foundation. This grant enabled UCSF Medical Center to hire Brinker and Carroll – both experienced cardiac floor nurses – to lead the initiative. They began by building a multidisciplinary team, including physicians, nurses, case managers, social workers, dieticians, chaplains and palliative care specialists. “We want to make sure that everyone is involved who should be,” says Brinker. “Because we know the players so well, we can pull everyone in when it is appropriate.”

This team identified the key issues in the care of heart failure patients and implemented processes to improve their care. Brinker and Carroll developed an e-mail system to notify inpatient and outpatient providers and other team members when heart failure patients are readmitted. They ensured that patients discharged from the hospital would receive a follow-up appointment with their primary care physician, or the outpatient heart failure clinic. “We realized that sometimes the outpatient clinics didn’t know when their patients were hospitalized, even though they are just across the street,” says Brinker.

They updated patient education materials, translated them into four languages and established better methods for teaching patients and their families about the disease and its management. Instead of cramming education into a hurried monologue on the day of discharge, Brinker and Carroll arrange to discuss different topics with patients each day they are hospitalized – and build relationships in the process. “We have the privilege of having time to spend at the bedside with patients and their families,” says Carroll. “Our mantra is, ‘Listen before we teach.’ Just taking the time to get to know the patient establishes a trust.” They trained team members in the “teach-back method,” asking patients to explain key concepts in their own words, which demonstrates comprehension and indicates if any points need to be explained another way.

They also call to check on patients within one week of discharge, again by day 14, and may make several more calls, depending on a patient’s needs. “They don’t think to tell us, but because we are asking, we find out things like they haven’t gotten their meds for three days,” says Carroll. “It’s a great way to troubleshoot.”

Receiving Care at Home

The most frail older heart failure patients are referred to GeriTraCCC, which stands for Geriatric Transitions, Consultation, and Comprehensive Care. The UCSF program was established in 2010 with support from the S.D. Bechtel, Jr. Foundation. “Our readmissions had gone down to a certain level during the first year of the heart failure program, but incorporating GeriTraCCC brought our readmission rate down quite a bit more,” says Carroll.

After a home visit, geriatrician Helen Kao, MD (right), and home health care nurse Laura Franklin discuss next steps.

“There is a subset of patients who need a higher level of follow-up to maintain their stability,” says Helen Kao, MD, GeriTraCCC’s medical director. Kao or a colleague makes a housecall to these patients within 48 hours of discharge, a critical transition period. They ensure that patients are taking the right amount of each medication, adjust doses as needed, and assess patients’ functional and cognitive abilities and their risk of falling. “GeriTraCCC is not meant to replace the primary care physician or cardiologist, but rather to extend their reach,” says Kao.

GeriTraCCC’s involvement might range from a few housecalls, to staying involved for months and enlisting a whole team, including nurses and physical therapists who can visit patients in their homes. “We can coordinate our schedules so somebody has an eye on that patient almost every day, so we have very good feedback on how they are progressing or declining,” says Kao. “It enables us to catch things a lot earlier than if they were only going to a clinic.”

Many GeriTraCCC patients have advanced heart failure, and about one-third die within a year. Kao discusses end-of-life wishes with her patients, and supports them in achieving the highest quality of life possible. “One patient was very sick, but taking care of her intensively at home enabled her to go with her spouse on a drive to Napa and to the opera – things that meant a lot to the couple in the final months before she died,” says Kao. “Some hospitalizations are very appropriate to keep someone safe, but there are many that are preventable, and we go to great lengths to help people stay at home. Having care come to patients at home is a far more economical and patientcentered way of providing care.”

For some patients with progressive late-stage heart failure, additional advanced heart failure management strategies may be employed, including heart transplantation or mechanical circulatory support (heart assist devices designed to pump blood to the body in patients with a failing heart). For those in whom all management options are exhausted or for whom they are inappropriate, palliative care, provided by a compassionate team, is instituted.

Michelle Mourad, MD (right), with Ellen Knoch, RN, study telemanagement techniques to reduce heart failure readmissions.

Sharing Innovations

The heart failure readmission reduction initiative is continuing to develop better ways to prevent unnecessary readmissions. “I would love to get our 30-day readmissions rate down into the single digits,” says Carroll.

One component is the “Better Effectiveness After Transitions – Heart Failure” (BEAT-HF) Trial, for which the five University of California medical centers and Cedars-Sinai Medical Center received a $9.9 million grant from the Agency for Healthcare Research and Quality. Andrew Auerbach, MD, MPH, and Michelle Mourad, MD, lead UCSF’s participation in this randomized study evaluating the effect of telemanagement techniques to reduce heart failure readmissions.

The heart failure team is also focusing on expanding collaborations with outpatient partners, training skilled nursing facilities and home care agency staff on optimal postdischarge care for heart failure patients. They are also working to apply lessons learned to reduce preventable readmissions among patients with other chronic diseases, such as pneumonia, diabetes, and chronic obstructive pulmonary disease. “What we have learned can be disseminated across all high-risk patients,” says Brinker. “All patients deserve this standard of care.”




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