Some 5.7 million Americans have heart failure (HF), a leading cause of hospitalization among people over the age of 65. According to the Centers for Disease Control and Prevention, half of those with HF die within 5 years of diagnosis, and costs associated with HF reach a staggering $30.7 billion in the U.S. annually.1 Since so many individuals within this specific at-risk population receive home healthcare, one organization has decided to get proactive with evidence-based population management in hopes of reigning in unnecessary hospitalizations and improving patient outcomes.
Bayada Takes Initiative
Bayada Home Health, based in Moorestown, N.J., piloted its HF initiative across nine offices in June 2015, and then rolled out this program across the company's entire home health practice - about 100 offices in 22 states - by last December. The initiative aims to standardize best practices and reduce variations of care among the various Bayada offices, clinicians and staff.
"We wanted to contribute to the larger healthcare system and focus on the 'Triple Aim,'" said Ashley Wharton, MSc, RN, Bayada Home Health's division director. Triple Aim is defined by the Institute for Healthcare Improvement as "improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of healthcare."2
"We recognized that the heart failure population is a very fragile one in need of a great deal of expertise," Wharton added.
Mandeep Mangat, MD, MPH, lead of the Heart Failure Management initiative, said an overarching goal was "to provide the best care to every patient through integrated clinical practice and education. The initiative was implemented to reduce hospitalizations, improve health outcomes and reduce costs for the HF population across the home health practice."
HF is a condition that exacerbates with age, Wharton told ADVANCE. "The average age of a heart failure patient in home health is 78 years old. We felt a comprehensive approach was necessary for managing heart failure in frail older adults."
Mangat added, "Not only does heart failure itself result in frailty, but its management also puts added stress on an already frail patient. In addition, the illness and its treatments can negatively affect comorbidities. Common signs and symptoms of HF are also less specific in older adults."
While the Bayada team undertook to identify and respond to challenges associated with care for patients with HF, Mangat said that medical care actually constitutes "a small fraction" of what ultimately affects an HF patient's health. Greater overall health determinants include "individual behaviors, social and physical environment," Mangat noted. "HF care delivery usually involves multiple clinicians and providers with no single entity effectually coordinating different aspects of care. Care fragmentation and lack of standardization of best practices is even more apparent for this population as it requires frequent monitoring and evaluation. Home healthcare teams are uniquely positioned to observe the impact of behavioral and social determinants of health and establish necessary relationships with patient, family and health professionals across care settings," she said.
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Realizing that one-size-fits-all homecare is not conducive to the best outcomes, diagnosis-specific care is needed to best serve HF patients, according to Wharton. "Therefore, we made a decision in our home health practice to make significant investments in clinical education."
Since a substantial portion of Bayada's workforce is mobile and distributed throughout different geographic regions, the HF initiative team needed to design a solution that was not only evidence-based and outcomes-driven, but also scalable, cost-effective and easy to implement.
"Our first priority was to identify all of the individuals involved in the care of a HF patient," explained Mangat. "While clinicians provide professional healthcare, non-clinicians - including social workers and home health aides - assist with a variety of issues such as adjustment to illness and coping skills. We mandated one-hour education across 100 service offices to elevate knowledge and skills of all clinicians and empower non-clinicians to escalate concerns to the interdisciplinary team."
This educational effort resulted in 280 Bayada certified heart failure specialists, each of whom received an additional 15 hours of specialized HF training. The initiative team also developed "Heart Talk: Living with Heart Failure," a patient education booklet that uses a six-step approach to help patients and caregivers self-manage HF. Some 15,000 copies have been printed to meet demands from patients and providers.
"The booklet has been wildly successful with patients and providers and has embedded tools for education and counseling," said Mangat. "We also aligned internal policies and procedures with evidence-based training and improved clinician skills to ensure timely and accurate documentation."
Results have been positive on different levels. Some 99% of the clinicians who participated in the training offered high ratings for the program, and agreed they would be able to implement at least one practice change based on the HF training. "Recently, a physical therapist mentioned in an open forum that his documentation has improved greatly after going through the HF program," said Wharton.
About 2,000 feedback comments from clinicians and non-clinicians have been collected through a survey instrument to reflect their agreement that the targeted HF education has increased understanding and management of the HF population. "It has improved assessment, management and documentation among our clinicians," Mangat added.
As for the patient-side results, they have been impressive. For HF patients admitted into homecare from the hospital, the initiative has led to an 11.6% decrease in hospitalizations within 30 days of admission and an 85.9% decrease in hospitalizations beyond 30 days of admission, said Mangat.
Moreover, "The initiative was successful in decreasing unnecessary utilization of nursing visits by 21.5% and led to improvements in HF patient outcomes measures including ambulation, dyspnea and pain interfering with activity," Mangat added.
Additional good news emerged in that as the initiative demonstrated a capability to effectively manage the HF population, Bayada experienced steady growth (300%) in HF Medicare Prospective Payment System admissions, averaging 26 HF admissions per week. Wharton proudly noted, "We saved the healthcare system money by reducing hospitalization costs."
Some Final Thoughts
Asked to characterize the takeaway messages gleaned from their experience with the HF initiative, Wharton said, "We should not underestimate the need to invest in ongoing education and training for our care providers. We are in the business of delivering evidence-based, high-quality healthcare."
Mangat took that message and expanded on it, noting, "Effective heart failure management requires an unwavering commitment from leadership to invest in prevention and disease management. Successful change necessitates developing an organized system of care and creating conditions in which care teams can become high-performing units. We all must recognize the need to effectually train teams and empower patients to self-manage their conditions proficiently."
Providing continuous support and effective care coordination to patients, and aligning internal policies, procedures and clinical pathways with evidence-based guidelines, Bayada was able to make an important inroad into HF population health management, both comprehensively and cost-effectively.
Valerie Newitt is on staff at ADVANCE. Contact: firstname.lastname@example.org.
1. Centers for Disease Control and Prevention. Heart Failure Fact Sheet. www.cdc.gov/dhdsp/data_statistics/fact_sheets/docs/fs_heart_failure.pdf
2. Institute for Healthcare Improvement, IHI Triple Aim Initiative. www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx