Reengineering Heart Failure Patients’ Discharge Management Utilizing a Risk Stratification Model and Multidisciplinary Team Approach Reduces 30-Day All Cause Readmission.

Introduction Value Based Purchasing (VBP) Initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. The challenge at our institution is the large volume of hospitalized Heart Failure (HF) patients (5,000/year) with historically high 30-day readmission rates (23%). Hypothesis Development of a designated multidisciplinary HF team (MD, NP, PharmD, and CM) that integrates a risk stratification model with a standardized comprehensive pre/post discharge management plan will decrease 30-day readmission rates. Methods May 1 - July 31, 2017 was the implementation phase of the HF-Readmission Reduction Initiative (HF-RRI) Pilot Project. During this time, approval of administrative leadership, credentialing of HF-NP staff, unit based RN and case management (CM) orientation, and inclusion of a designated PharmD specializing in HF was completed. August 1, 2017 began the HF-RRI process which included generation of a daily patient list with Primary HF (ICD-10) and their associated HOSPITAL (risk for readmission) Score. Daily HF Team morning rounds were conducted to review patient/family education, appropriate medication/adherence, and discharge readiness. HF patients with an intermediate to high risk HOSPITAL Score were flagged for further in-depth pre-discharge HF NP consult/PharmD counsel, post discharge CHF Clinic 7-day appointment and weekly telephone assessments. Retrospective review of prospectively collected data was analyzed based on age, gender, length of stay (LOS), NYHA, HOSPITAL Score and 30-day readmission. Time periods included Pre-HF-RRI (November 1, 2016 -April 30, 2017); Implementation Phase (May1, 2017-July31, 2017); Post HF-RRI (August 1, 2017-January 31, 2018). Results We identified 242 Primary HF patients (116-Pre-HF-RRI and 126 Post HF-RRI). Continuous variables (age, LOS and risk score) and categorical variables (age75+, gender, NYHA, and 30-day readmission) were summarized; pre/post groups were compared using Wilcoxon rank sum and chi-square tests, respectively. The groups were comparable on age and gender. There were no differences in LOS, NYHA or HOSPITAL score. The 30-day readmit rate was statistically significantly lower in the POST HF-RRI group compared to the PRE HF-RRI group, 10.3% (12/116) vs. 20.6% (26/126), respectively, p=0.0279. Conclusion Our newly integrated multidisciplinary HF team approach that incorporates a risk for readmission HOSPITAL Score stratification can prevent avoidable 30-day readmissions.