Patient Care

Successful Heart Failure Program Highlights the Roles of Nurses and Nursing Research in Health Care Reform

November 2011Andrew Schwartz

Even within the highly charged debates about health care reform, few disagree with its central goals: higher-quality outcomes for all patients; more efficient, coordinated care; and a lowering of cost increases, if not outright savings.

Unnecessary hospital readmissions indicate failure toward all three goals, which is why, in 2012, Medicare payments to hospitals will be at risk due to readmissions for at least three conditions. One of those conditions is heart failure, which represents Medicare’s highest readmission rate. Approximately half of heart failure readmissions are considered potentially preventable, according to a 2003 article in the Journal of the American College of Cardiology.

Pilot programs nationwide have shown that better transitional care can reduce readmissions and improve these patients’ quality of life. Controlling costs has been more elusive, but any program too costly is not likely to be widely replicated. Such a challenge makes it notable that when, from January 2009 to the end of 2010, UCSF Medical Center cut its 30-day and 90-day heart failure readmission rates by approximately 30 percent, it met all three goals in the process.

Nurses have been essential. Of the many people who contributed to the program’s success, only a few don’t have an RN after their names.

Patricia Rutherford “Nurses are ideally positioned to lead initiatives to reduce avoidable rehospitalizations, oftentimes taking the primary role in preparing patients and family members for discharge and in communicating with clinicians and staff in various sites of care,” says Patricia Rutherford, vice president at the Institute for Healthcare Improvement (IHI), a national organization focused on patient safety, and a collaborator with UCSF on the project. A nurse herself, Rutherford says that many promising interventions have emerged to help reduce readmissions, but successful implementation requires effective leadership on the front lines of care.

“This has been an extraordinary effort from a lot of people, but I do think the nurses [heart failure discharge coordinators Maureen Carroll and Eileen Brinker] have been the conductors,” says Jill Howie-Esquivel from UCSF School of Nursing, an adviser on the $575,000 grant from the Gordon and Betty Moore Foundation that jump-started the heart failure program. “Maureen, Eileen and [service line manager and nurse] Karen Rago stood up and risked their reputations to bring all these people together. They took the reins and are the driving forces behind the program’s success.”

Gathering the Pieces

Left to right: Jill Howie-Esquivel, Eileen Brinker, Karen Rago and Maureen Carroll confer in the heart failure office, a converted storage closet. Two of the three driving forces began their work in a closet.

After Rago and Maureen Buick, another RN who is director of patient education and performance improvement, successfully wrote the grant and brought in Howie-Esquivel to administer it, Carroll and Brinker needed an office. They commandeered a storage closet in the heart and vascular unit, where they had been staff nurses for many years.

Initially, the Moore Foundation connected them with the IHI for training in the four principles that make up the program’s foundation:

  1. Enhanced admission assessment for post-discharge needs
  2. Enhanced teaching and learning
  3. Patient- and family-centered handoff communication
  4. Post-acute care follow-up

“Our task was to figure out where the gaps were in our own programs and how we could adapt this to UCSF,” says Brinker.

It quickly became clear that while there were many skilled, experienced heart failure clinicians at UCSF and in the surrounding community, they tended to operate in silos. Therefore, Carroll and Brinker reached out to clinicians at UCSF Medical Center, UCSF Home Health Care, skilled nursing facilities, UCSF Division of Geriatrics and UCSF School of Nursing. “We talked with anyone who could be the point person for developing a multidisciplinary team, and began to develop relationships,” says Carroll. It culminated in an initial meeting that generated considerable excitement.

Pat Sparacino “We all know how difficult it can be to manage heart failure patients, and people seemed thrilled to be a part of a project to make their lives better,” says Pat Sparacino, a UCSF School of Nursing professor who served as an adviser on the project. She spent many years working with heart failure patients as a clinical nurse specialist in the medical center and home health care.

It was the first in a series of meetings that continue to this day. Nearly everyone involved credits the meetings – as well as the passion, persistence and knowledge of Carroll and Brinker – with playing a crucial role in breaking down silos and sustaining the program’s successes.

“Karen engaged two expert nurses to lead the work,” says the IHI’s Rutherford. “Maureen and Eileen were passionate about improving patient care and were very effective in engaging a multidisciplinary team within the hospital and with clinicians and staff that provide community-based care.”

At the Bedside

That doesn’t mean it was or is easy. In addition to tightening the loop with outpatient settings, in the hospital, Brinker and Carroll must be vigilant about keeping patients, families, physicians, bedside nurses, pharmacists, the lab, rehab, care managers and administrators moving together efficiently toward the goal of improved quality of life.

For patients and families, the effort has changed the entire inpatient experience.

For one, in most settings, a bedside nurse has only five to 10 minutes for the initial assessment. Carroll and Brinker often spend at least 45 minutes with each patient to hear the individual stories that help tailor the goals-of-care plan and education.

“If you’re going to effect change, you have to be well informed about best practices that can impact readmissions,” says Howie-Esquivel. One such best practice in the literature – confirmed by Howie-Esquivel’s analysis of the initial months of the program – is that assessment demands time.

Carroll and Brinker also transformed the education process. They use and teach to other nurses “teach-back,” a technique in which nurses ask patients to demonstrate what they understand so that the nurses can recognize and fill in the gaps. In addition, the old patient education handouts consisted of one page that was 10 years old and available only in English. Today, there is a binder available in four languages that anyone within the UC system can order. And a group of acute care nurse practitioner students from UCSF School of Nursing conducts weekly classes for patients and their families.

That – along with a constant presence and follow-up – is crucial. “We’re here seven days a week,” says Carroll. “Patients know who we are, which builds trust and gets us information that allows us to focus on what will work for each individual.”

In addition, because Carroll and Brinker carefully follow the progress of every heart failure patient, they are in an ideal position to coordinate the work of other clinicians.

Working with the Doctors

For example, it’s long been known that physician buy-in is essential for such concerns as home health care referrals and coordinating with other outpatient providers, but busy cardiologists needed to be convinced of the value of the program and residents come and go so quickly that engaging them is a never-ending process. Carroll and Brinker relentlessly reach out to physicians by crisply presenting research data and program results, and asking clearly and succinctly for what they need to foster continued success.

“It helps a lot that we’ve had great senior support in Karen and the readmission task force at the hospital, and that many doctors have become real believers,” says Carroll.

“We all want these patients to do well, and I think there comes a time when the cardiologists become aware of the whole package that we offer and become very welcoming,” says Brinker.

A clever, HIPAA-compliant email system that kicks into gear at the outset of an inpatient stay and extends through outpatient care has also eased the buy-in, while creating a virtual team that leads to the timely care adjustments so essential for heart failure care.

Outpatient Coordination

The email chain has certainly enhanced the ability of UCSF Home Health Care to manage these frail patients.

“A lot of times, [to avert an ER visit] we need to be able to contact a physician to get direction around medication,” says Barbara Maury, a nurse and clinical manager at UCSF Home Health Care.

In many other settings, when home health care nurses call a physician’s office, they typically reach an assistant and the doctor might not respond for a day or two. “Often it’s that 24- or 48-hour delay that results in rehospitalization,” says Maury. “The virtual email system gives us the ability to contact doctors in real time and make immediate changes to the patient’s medi-set while we’re still in the home.”

An Eye on the Patient’s Big Picture

In many cases, one of the providers that the email reaches is geriatrician Helen Kao.

Kao runs the GeriTraCCC Heart Failure Transitions service, a key piece of the UCSF program that ensures that the frailest older adults who are returning home from hospitalization for heart failure receive a physician house call within 48 hours of discharge. She works with other treating physicians and UCSF Home Health Care, providing expertise in the complexities of older adult care during a time when there can be changes in medication, new symptoms, greater difficulty in doing basic activities and difficulty in making it to a doctor’s office visit.

After a home visit, geriatrician Helen Kao and home health care nurse Laura Franklin discuss next steps. “We try to keep the medical condition stable,” says Kao. “But we also help patients achieve their own goals, of perhaps visiting a family member or being able to sit in a chair long enough to attend a concert. What’s unique is that patients see the same face from one setting to another; this helps us facilitate understanding of the patients’ goals of care – their big picture – so things don’t slip through cracks.”

To illustrate why the big picture matters, Sparacino tells of a patient who seemed to be in the ER every week until a home health care nurse asked what he would most like at this point in his life, and he told her that he wanted his two sausages for breakfast every morning. “So they worked with the patient to eliminate every other source of sodium, he was never back in the hospital, and he died a very happy man, nine months later, of an arrhythmic death,” says Sparacino.

Connecting the Clinic

Delivering care to every patient at home, however, is not a practical option. Many patients continue to need regular clinic visits if they are to maintain a reasonable quality of life and avoid the hospital.

Cardiologist Teresa De Marco, who directs the UCSF advanced heart failure, transplant and pulmonary hypertension clinics, recognized that her expert team could fill a need. She connected with the heart failure program and opened her clinics to chronic patients who were not necessarily slated for transplant.

Nimaljeet Tarango with patient Grace Johnson “We are now seeing many of these patients, usually ones Maureen and Eileen identify as at high risk of readmission,” says Nimaljeet Tarango, one of two nurse practitioners in the heart failure clinic. She and Carroll began together as bedside nurses; Tarango eventually went on to graduate from UCSF School of Nursing’s Gerontology Nurse Practitioner program.

In the clinic, after an initial evaluation by a cardiologist, Tarango and her nurse practitioner colleague Lynn Oveson become the point clinicians for heart failure patients. As such, their nurse practitioner training comes in handy.

“We collaborate with the PCP and the cardiologist, but we have to know more than heart failure because that condition is usually accompanied by other conditions, like COPD or diabetes or chronic pain,” says Tarango. “And we have to consider those things, even if our goal here is to optimize volume status using guideline-based best practices.”

Outside the UC System

For patients not healthy enough to either return home or travel back and forth to clinic appointments, post-hospitalization means time at a skilled nursing facility. Kindred Healthcare has five post-acute care facilities and 585 beds in San Francisco, including one dedicated cardiopulmonary floor staffed by RNs. Because it is a major referral center for UCSF, Carroll and Brinker linked Kindred’s Diane Testa into the heart failure program from day one.

“The process is simple because we have centralized admissions,” says Testa, Kindred’s district director of sales development. “Maureen and Eileen give me the heads-up that one of their patients is heading our way. I inform our admissions coordinators to put a heart sticker on the referral.”

This sets off a process that often begins with Kindred clinical liaisons meeting with the patients before they leave the hospital. When the patients arrive at Kindred’s cardiopulmonary floor, a nurse practitioner meets them to ensure a smooth handoff. Nurses on the floor are all certified as to their competencies, and equipment on the floor includes EKGs.

“Also, Maureen and Eileen have done a great job of making our nurses aware of teach-back techniques, and all this makes the patients feel they are part of a continuous program,” says Testa. “In fact, we’ve begun instituting teach-back on all diagnoses.”

Refining the Program

Despite its successes, perhaps the heart failure program’s most impressive attribute has been the ability of the teams to adapt to change. The virtual emails offer a perfect example.

“In the beginning, there were these long, complicated emails,” says Tarango. “We needed to find a way to edit them and make sure important players get information they need and not more than that.”

The solution, to date, is to make sure that subject headings always include the patient’s name and the date of an encounter. Action items appear in color, in bold print, with the name of the relevant provider.

“If I’m requesting feedback from a cardiologist on a diuretic, they know if there’s an action item next to their name as soon as they open up the email,” says Kao.

People also learn directly from patients. “We had a classic heart failure patient whose wife, three days after discharge, said she wasn’t happy with me because her husband was up 12 pounds,” says Carroll. “This didn’t make sense until we realized the patient hadn’t been getting daily weights while at the hospital.” It prompted system changes that enforced daily weigh-ins.

A Feedback Loop with the School of Nursing

The program has also undergone continual improvements because of close collaboration with the School of Nursing.

“For example, Jill [Howie-Esquivel] took some of our teach-back data and did a great analysis that showed it takes about 36 minutes to do teach-back properly,” says Brinker.

Master’s student Matthew White based his thesis on the same teach-back data. His paper was the first of its kind to confirm the efficacy of the teach-back process. It was accepted as an abstract at the 2011 Heart Failure Society of America meeting, and is under review for publication in the Journal of Cardiovascular Nursing.

Howie-Esquivel’s work also has changed the content of some patient discussions. “We are often struck with how many people don’t understand they have a chronic and serious disease,” says Brinker.

But after Howie-Esquivel’s analysis of the data Carroll and Brinker had provided revealed that 25 percent die within a year of hospital admission, they had a new and more effective way to get patients’ attention. “It helped us emphasize how serious this is, and also gave us increased credibility to ask for palliative care consults, which are another critical aspect of our program,” says Brinker.

In addition, while the original program prescribed a first follow-up call within a week and a second follow-up call on day 30, the data showed many patients being readmitted by about day 17. This changed the second follow-up call to the two-week mark.

The Hard Numbers

Even with its successes, Rago, Carroll and Brinker were acutely aware that the program’s long-term survival depended on its ability to demonstrate that the combination of a shared, 1.6 full-time position for Carroll and Brinker and the loss of revenue from a smaller census of heart failure patients could largely be offset by the savings generated by three factors: avoiding the inadequate reimbursement for heart failure patients’ complex care in the hospital, avoiding the specter of a Medicare crackdown on paying for readmissions, and increasing the number of inpatients with conditions that require higher reimbursement procedures.

“If we didn’t have the data – and support in senior leadership – this program could have come and gone,” says Carroll.

Rago was determined not to let that happen. She had been gathering data all along that compared numbers from the time period before the program was instituted to numbers of the next two years.

“I couldn’t say we made up the margin one for one, but we offset it quite a bit and that’s before 2012, when CMS begins withholding money,” she says. “We also increased patient satisfaction, and know this is the right thing to do for patients.” Rago hoped all of these things would make a strong argument for the hospital to fund the program itself.

Already focused on reducing preventable readmissions, administrators at UCSF Medical Center were convinced. They have funded most of the position that Carroll and Brinker share, with the rest covered for now by a universitywide, three-year grant from the Agency for Healthcare Research and Quality. The study, called Better Effectiveness After Transition-Heart Failure (BEAT-HF), will test the efficacy of telemedicine in contributing to reduced readmissions in an efficient, cost-effective way.

A Lot of Learning

In an effort to share what the program has learned to date, on June 3, 2011, Rago organized a Heart Failure Summit for all five UC Medical Centers, plus Cedars-Sinai Medical Center in Los Angeles. Funded by the Moore Foundation, the summit drew so much interest that Rago had to cut off registration when it hit 70. She, Carroll and Brinker also speak about the program around the country.

When they do, Carroll and Brinker emphasize that they had some unique advantages, most notably their freedom to focus all their attention on this program. “I also think it’s very beneficial to have two people in the position. We’re constantly bouncing ideas off each other,” says Brinker.

Yet both say it’s important to realize there is not one way to make this work. “We are not these know-alls,” says Carroll. “It’s more a matter of saying, ‘These were our challenges; this is what worked and didn’t work.’”

“That’s an important perspective,” says Sparacino. “Because as magnificent as this program is, it didn’t happen overnight. There have been decades of attempts from various groups to improve heart failure treatment, and all the pieces are necessary.”

Still, nearly everyone agrees that an indispensable ingredient is the leadership that Rago, Brinker and Carroll have provided.

“Maureen and Eileen are passionate about this work and exemplary nurses,” says Rutherford. “They were prepared, loved the challenge, were quick studies and always had patients top of mind. Plus they had executive leadership in Karen, physician champions, and a group of people willing to take risks and go after a new level of performance.”