From Knowledge to Practice Translation A Multidisciplinary Intervention to Reduce 30 day Heart Failure Readmissions.

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Presentation transcript:

From Knowledge to Practice Translation A Multidisciplinary Intervention to Reduce 30 day Heart Failure Readmissions

Context Rehospitalization ≤30 days marker of poor quality – Reduction of unnecessary rehospitalization is a way to improve quality and decrease cost Limited data re: patterns of rehospitalization in U.S. Jencks et al. (2009) NEJM – What is the frequency of rehospitalization of Medicare patients within 30 days after discharge? – How long does the risk of rehospitalization persist? – What is the frequency of outpatient followup after hospitalization? Jencks S et al. (2009) NEJM 360(14):

30 day rehospitalization 19.6% of all Medicare patients rehospitalized within 30 days of discharge – Medical diagnoses – 21.1% Heart failure – 26.9% – Surgical diagnoses – 15.6% No record of outpatient follow-up visit for 50.1% of patients rehospitalized within 30 days after discharge No outpatient follow-up visit for 52% of those rehospitalized within 30 days after discharge for heart failure Jencks S et al. (2009) NEJM 360(14):

Heart failure readmission and HLOS relationship Winslow R, Wall Street Journal, June 2, 2010

The Allen Hospital Project Graham et al., 2006

28.3%

The population

Strategy

Teambuilding

Preparatory work

Intervention components

Practice change

Effect on 30 day readmission

Would improvement have happened anyway?

Core measure improvement

Lessons Learned But the story doesn’t end here…..

Ongoing Monitoring 2012 Rise in readmission rates Characteristics of those readmitted analyzed Chronic kidney disease Dementia Respiratory diseases Poor social support Medication discrepancies Review of meds by pharmacist prior to discharge Need for palliative care team