Running head: AVOIDABLE READMISSIONS1
Avoidable Readmissions Among Patients with Heart Failure
Corine Domingo
Liberty University
AVOIDABLE READMISSIONS 2
Introduction
Heart Failure is a chronic, progressive condition where the heart muscles are unable to
pump sufficient amounts of blood to meet the body’s need for blood and oxygen causing the
heart to overwork. This patient population is at a higher risk of hospital readmission compared to
other chronic conditions due to its significant mortality rate and poor prognosis. According to the
Centers for Disease Control and Prevention (CDC), approximately 6.5 million adults in the
United States have Heart Failure (HF), with an increase to 8.5 million by 2030. In the last three
years, Heart Failure was a contributing factor to every 1-in-8 deaths while costing the nation an
estimate of $30.7 billion in health care services, medications, hospital readmissions (U.S.
Department of Health & Human Services, 2019). Patients with heart failure experience changes
in their quality of life and overall well-being, therefore it is important that we learn how to
modify patient outcomes by suggesting and implementing interventions that exhibit continuum
of care. However, it is equally important to measure the effectiveness and sustainability of these
interventions on how well they can identify patients at high risk of rehospitalization (Shams et
al., 2014, p. 19).
To overcome that bridge, the Centers for Medicare & Medicaid Services (CMS)
introduced one such intervention, Hospital Readmissions Reduction Program (HRRP), a
Medicare value-based purchasing program to reduce payments to hospitals with excess
readmissions. This intervention is geared towards supporting “the national goal of improving
healthcare for Americans by linking payment to the quality of hospital care” ("Hospital
Readmissions Reduction Program (HRRP)," 2020). Throughout, the remainder of this paper we
AVOIDABLE READMISSIONS 3
will discuss several transitional care interventions and elaborate on the program(s) and incentives
set by CMS to reduce the 30-days hospital readmission rates for patients with heart failure.
Overview of Selected Population
For this population health intervention project, the selected population data will be
carried out utilizing data from the national 5% sample of Medicare beneficiaries from the
Chronic Conditions Warehouse which is the national repository for CMS data. (Kilgore et al.,
2017, p. 64). The population included individuals aged ≥65 years with at least one inpatient
(International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]
diagnosis code of HF as the primary diagnosis. For the purpose of this project, the definition of
HF includes left ventricular, right ventricular, combined and unspecified HF. To analyze the rate,
cost, and length of stay of hospitalizations, the population edibility criteria also included patients
with a minimum of six (6) month enrollment under Medicare Part A and B prior to the index date
and 36 months of continuous enrollment following the index month. Index date is defined by the
first observed HF-associated hospitalization (Kilgore et al., 2017, p. 63-64).
Disease-specific Data
HF is a complex and collective clinical condition which results from any functional or
structural cardiac impairment simultaneous with “comorbidities, which frequently include
hypertension and coronary artery diseases. Cardiac dysfunction in HF is often described using
values of cardiac output (Q), stroke volume (SV), or resting EF% which are abnormally low and
may be useful for estimating syndrome severity and prognosis (Snyder et al., 2015, p. 207).
According to the article, Two types of heart failure, (2015) the two forms of HF are systolic and
AVOIDABLE READMISSIONS 4
diastolic differentiated based on ejection fraction (the amount of blood the heart pumps out with
each contraction). A normal ejection fraction is about 55 to 65 percent, with that in mind,
Systolic HF is diagnosed when the left ventricle becomes large and contracts so feebly that its
blood is not expelled throughout the circulatory system efficiently; individuals with this
condition have ejection fractions of 10 to 55 percent. On the other hand, diastolic heart failure is
when the heart’s pumping strength is preserved, and the ejection fraction is normal. However, the
ventricles don't relax properly, which meaning they heart does not have sufficient time to fill
effectively (pg. 6).
As discussed earlier, currently HF affects 1-2% or approximately 6. 5 million of the
general population and over 800,000 new cases are diagnosed annually. The prevalence is on a
rise with an estimated increase to 8.5 million by 2030 (U.S. Department of Health & Human
Services, 2019); all of which leads to increased levels of morbidity and mortality rates, decreased
quality of life and increased care costs. “HF patients are particularly vulnerable to readmission;
all-cause readmission rates have been reported as between 5.6% after 30 days and 45% after one
year” (Duflos et al., 2016, p. 1). Therefore, improving access and effectiveness in care could be
substantial in decreasing overall re-admission rates and quality of life for patients with HF.
Setting
For the purpose of this population health intervention, the setting will be at the
community level, specifically, Montgomery County, Maryland. “The six hospitals operating in
Montgomery County, Maryland have joined forces with a network of community-based
organizations to form the Nexus Montgomery Regional Partnership. Nexus Montgomery is a
hospital-led collaborative that aims to reduce avoidable or unnecessary hospital use (including
AVOIDABLE READMISSIONS 5
readmissions), by connecting people to timely and appropriate community-based care and
support service. ("ABOUT US – Nexus Montgomery," 2018). Continuum of care is vital in
managing high-risk populations, such as patients with HF, therefore care at the hospital level and
discharge to the community will be a good indicator for transition of care.
Cultural Consideration
“Cultural and language differences may be important determinants of health outcomes
among minority patients with chronic conditions such as HF, which require frequent interactions
with the healthcare system. Patients with low acculturation or less integration into mainstream
US culture may have greater challenges with such interactions” (Peterson et al., 2012, p. 160).
Certain factors that could limit an individual’s ability to services that may assist in exacerbation
of HF signs and symptoms may include disease perception, language barriers, and lack of
cultural competency among providers (Peterson et al., 2012, p. 160). Furthermore, in an article
published by Harvard Health, certain minority groups like African Americans, Hispanics, and
Asians tend to be at a greater risk for high blood pressure, diabetes, and obesity, which lead to
other chronic conditions and comorbidities compared to white Americans (Harvard Health
Publishing, 2019). Therefore, for the purpose of this health intervention the sample population
would include a range of racial and culturally diverse cases.
Suggested Intervention
With improvements in medical therapies and interventions management of HF has
progressed over the last few decades. According to the article by Ziaeian & Fonarow, (2015),
studies indicate a reduction in length of stay (LOS) and 30-day mortality in patients with HF as,
AVOIDABLE READMISSIONS 6
however there is an increase of 30-day readmission rates and discharges to skilled nursing
facilities. Among Medicare patients “the daily risk of readmission was highest on day 3
after discharge. Not until 38 days after hospitalization did the daily readmission risk decrease by
50%” (Ziaeian & Fonarow, 2016, p. 380). While the 30- day admission rates are increasing,
many hospitals are switching gears to improve quality, inpatient interventions for efficiently
preventing or reducing readmissions. Also, increase efforts to focus on “reducing 30-day
readmissions as they are perceived as a modifiable event after hospitalization, risk standardized
readmission rates are publicly reported, and hospitals face substantial financial penalties from
CMS” (Ziaeian & Fonarow, 2016, p. 383).
In the era of reimbursement penalties, opportunities for collaboration amongst healthcare
professionals during transitions of care (TOC) is at its prime, such efforts can “have a significant
impact on patient outcomes while also contributing to the reduction of unnecessary 30-day
hospital readmissions and, ultimately, healthcare-related costs” (Boykin et al., 2018, p. 45).
Currently eight (8) common transition of care themes or interventions have been derived from
various care models, inducing the Bridge model, Care Transition model, and the Enhanced
Discharge planning Program (EDPP), Post discharge Care Transition (PDTC), Partners in Care
for Congestive HF (PCCHF), etc. (Albert, 2016, p. 101).
Intervention 1: planning for discharge
Discharge planning for a patient with HF or any other chronic condition should be initiated and
implemented on day one of hospitalization. An Interdisciplinary Team (IDT) including the
pharmacist and any community outreach nurse or clinician should discuss the social, economic,
cultural, religious and other factors that might impact discharge planning. During discharge
AVOIDABLE READMISSIONS 7
planning IDT should include rationale for a 7-14-day follow-up and a discussion of signs and
symptoms of worsening HF should be reviewed with the patient as it might help them in
recognizing factors that they previous ignored prior to the hospitalization index (Albert, 2016,
p. 101).
Intervention 2: multi-professional teamwork, communication, and collaboration
“Communication failures among outpatient providers of care and patients (particularly in
follow-up and tracking of patients) were associated with delays in diagnosis and treatment, and
uncoordinated care among providers was associated with patient perceptions of conflicts among
providers” (Albert, 2016, p. 101). Due to the complexity of patients with HF collaboration and
teamwork is needed to discuss health care needs; it is prudent for HF programs to include
explicit standards for multidisciplinary communication between service providers and explicit
standards for processes and systems that ensure provider accountability” (Albert, 2016, p. 108).
Muti-professionals communication during all stages of a hospitalization is vital in a successful
discharge. Many patients and families are overwhelmed and have conflicting feelings of anxiety
or relief during transition from a hospital to a home setting; therefore, effective communication
between health providers and the party involved is crucial.
Intervention 3: timely, clear, and organized information
“The Care Transitions model, Project RED, and the American Heart Association
(AHA)/The Joint Commission (TJC) certification program required that important discharge
information be available to outpatient providers within 72 hours to 7 days of hospital discharge
and include standardized content” (Albert, 2016, p. 108). All related information should be
presented to patient and families in a timely and clear manner. Discharge-transition information
AVOIDABLE READMISSIONS 8
includes all medication with dosage, timing, indication of use, treatments and services including
labs, nutritional needs, etc. provided during the hospitalization. Provider information along with
community resources should be handed off to patients and families in an organized manner as
well.
Intervention 4: medication reconciliation and adherence
“Medication safety is crucial in HF management. In various a quality improvement
initiative reports indicated 87% of patients had discrepancies between discharge and follow-up
medication lists, and 26% had changed, about 42% to over 50% of patients had medication errors
after hospital discharge” (Albert, 2016, p. 109). Medication adherence is an important part of
patient safety, failure in doing so can cause exacerbation of HF and lead to re-hospitalization and
decreased quality of life. It is important for the IDT to evaluate any patient-specific factors like
fear of adverse effects of medications, costs, literacy/comprehension issues. “Careful medication
reconciliation at hospital admission and discharge and at each ambulatory visit can inform health
care providers about medication safety issues” (Albert, 2016, p. 109). Medication reconciliation
is a time-consuming task, health care providers should develop procedures and techniques that
facilitate and standardize this.
Intervention 5: engaging social and community support groups
Many studies have found that social and community support groups for patients with HF
have allowed these patients to gain assistance with household activities, meals, medication
management, and more. Moreover, social and community programs provide patients with
emotional and financial support in addition to physical and social support (Albert, 2016, p. 109).
AVOIDABLE READMISSIONS 9
Intervention 6: monitoring and managing signs and symptoms after discharge with follow
ups
After discharging it is important for patients and families to monitor for new or
worsening HF signs and symptoms as they can lead to early interventions and prevent
hospitalization or emergency care visits. Patient education on HF should be initiated during
hospitalization, at discharge, and followed through after discharge. Clinicals should “encourage
patients to ask questions and to be engaged in preventive measures and HF self-care
expectations. Emphasize the importance of weighing self every morning (at the same time) after
urinating, before drinking, wearing the same amount of clothing, and using the same scale,
discuss diet medications and ability/willingness to follow diet restrictions (Albert, 2016, p. 110).
Cardiac monitoring options and strategies “that identify subclinical congestion before HF
exacerbation may increase proactive care and prevent further clinical decline and
hospitalization” (Albert, 2016, p. 110).
Intervention 7: outpatient follow-up
“Early outpatient follow-up is an important point of interface for providers and patients
with HF” (Albert, 2016, p. 111). Follow-up visits re-assess patient’s current status, medication
management and reconciliation, reinforce patient education, further assess social and community
support and barriers and discussion of advanced-care planning (Albert, 2016, p. 111). It has been
reported that 30-day re-hospitalization rates decrease when 7-day follow up visits are
implemented.
AVOIDABLE READMISSIONS 10
Intervention 8: advanced care planning and palliative/rend-of life care
According to Albert, (2016) it is important for all multidisciplinary team members to
discuss HF chronicity and prognosis with patients and families, including the potential need for
palliative care and the possibility of cardiac failure or sudden death (pg. 111). Many patients and
families have misconceptions about the chronic and deteriorating nature of HF, therefore setting
realistic expectations and discussing palliative care needs might promote the need for advanced
therapy and adherence of self-care and medication management.
Budgetary Needs and Possible Funding
The Maryland Health Services Cost Review Commission has awarded the Nexus
Montgomery partnership program with $7.6 million to address the challenges affecting the health
and safety of the county and to “implement or expand initiatives that will improve the health
status of those most at risk of avoidable hospital use” ("Montgomery County Hospitals
Announce Funding of Nexus Montgomery Regional Partnership," 2018).
Timeline for Implementation and Evaluation Methods
The Nexus Mo ntgomery program initat4d in 2018 and plans to implement success
interventions and transition of care models throughout the county with a 5-year plan to begin
with. The first year The Nexus Montgomery program partnered with six (6) local hospitals and
strategized plans to recruit and organize ways to improve quality and care for the patients in the
community. The program participants meet quarterly and monthly if needed to discuss progress
and barriers. Each of the six hospitals have a set goal and target re-admission rate for each
quarter, furthermore, these hospitals work in conjunction with preferred SNFs and home health
agencies to ensure community and/or SNF discharges are effective and quality care is continued
AVOIDABLE READMISSIONS 11
throughout, all in effort to reduce readmissions. Hospitals and adjacent facilities that do not meet
the target goals are offered 1:1 focused meetings to understand the barriers and help improve
their outcomes.
QSEN Competencies
In 2003 Institue of Medicine (IOM) published a report called Health Professions
Education, which highlighted the importance of healthcare quality and safety; this lead to the
development of the Quality and Safety Education for Nurses (QSEN) and six (6) core “quality
and safety program competencies that are essential in closing the gap between the quality chasm.
These competencies are patient-centered care, teamwork and collaboration, evidence-based
practice, quality improvement, safety, and informatics” (Lyle-Edrosolo & Waxman, 2016, p. 73).
In management of HF and reduce 30-day readmission rates it is important to recognize
the need for teamwork, collaboration, and delivering patient-centered care. Teamwork and
collaboration as discussed are crucial in the transition care model as patients require education,
follow-up and support once they are at a community level or in an acute care setting. Patient-
centered care is important as the multidisciplinary team should evaluate patient-specific barriers
such as social, economical, or personal to implement effective ways in management thir disease
process and improve quality of life.
Christian Worldview
John 13:34-35 reads, "A new commandment I give to you, that you love one another,
even as I have loved you, that you also love one another. "By this all men will know that you are
My disciples, if you have love for one another.” As a Christian nurse it is important to recognize
the struggles and the success of individuals all we care for. Upon deciding to become a nurse, it
AVOIDABLE READMISSIONS 12
was important to understand that not everyone who will be encountered during this journey will
be “people of God” many may have done wrong and drifted from the path God had created for
us, however it is up to us to lead by his example and love all as one. Working in a prison and
different healthcare settings, this theory has been tested a few times, however keeping in mind
that God is the ultimate judge and will guide us all is kept me going. In conclusion, reducing the
30-day readmission rate is a crucial initiative and understanding the need for opportunities that
would improve delivery of care, encourage collaboration and teamwork all while providing
patient-centered and quality care are instrumental.
AVOIDABLE READMISSIONS 13
References
ABOUT US – Nexus Montgomery. (2018). Nexus
Montgomery. https://nexusmontgomery.org/about-us/
Albert, N. M. (2016). A systematic review of transitional-care strategies to reduce
rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100-
113. https://doi.org/10.1016/j.hrtlng.2015.12.001
Boykin, A., Wright, D., Stevens, L., & Gardner, L. (2018). Interprofessional care collaboration
for patients with heart failure. American Journal of Health-System Pharmacy, 75(1), 45-
49. https://doi.org/10.2146/ajhp160318
Deedwania, P., & Rathi, S. (2017). Epidemiology and Pathophysiology of Heart
Failure. Medical Clinics of North America, 96(5), 881-890.
Duflos, C. M., Solecki, K., Papinaud, L., Georgescu, V., Roubille, F., & Mercier, G. (2016). The
Intensity of Primary Care for Heart Failure Patients: A Determinant of Readmissions?
The CarPaths Study: A French Region-Wide Analysis. PLOS ONE, 11(10), 1-
13. https://doi.org/10.1371/journal.pone.0163268
Harvard Health Publishing. (2019, September 24). Race and Ethnicity: Clues to Your Heart
Disease Risk? Harvard Health. https://www.health.harvard.edu/heart-health/race-and-
ethnicity-clues-to-your-heart-disease-risk
Hospital Readmissions Reduction Program (HRRP). (2020, February 11). CMS Homepage |
CMS. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
Kilgore, M., Patel, H., Kielhorn, A., Maya, J., & Sharma, P. (2017). Economic burden of
hospitalizations of Medicare beneficiaries with heart failure. Risk Management and
Healthcare Policy, Volume 10, 63-70. https://doi.org/10.2147/rmhp.s130341
AVOIDABLE READMISSIONS 14
Lyle-Edrosolo, G., & Waxman, K. (2016). Aligning Healthcare Safety and Quality
Competencies: Quality and Safety Education for Nurses (QSEN), The Joint
Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards
Crosswalk. Nurse Leader, 14(1), 70-75. https://doi.org/10.1016/j.mnl.2015.08.005
Montgomery County Hospitals Announce Funding of Nexus Montgomery Regional Partnership.
(2018). Adventist HealthCare |
Maryland. https://www.adventisthealthcare.com/news/2016/montgomery-county-
hospitals-announce-funding-nexus-montgomery/
Peterson, P. N., Campagna, E. J., Maravi, M., Allen, L. A., Bull, S., Steiner, J. F.,
Havranek, E. P., Dickinson, L. M., & Masoudi, F. A. (2012). Acculturation and
Outcomes Among Patients With Heart Failure. Circulation: Heart Failure, 5(2), 160-
166. https://doi.org/10.1161/circheartfailure.111.963561
Shams, I., Ajorlou, S., & Yang, K. (2014). A predictive analytics approach to reducing 30-day
avoidable readmissions among patients with heart failure, acute myocardial infarction,
pneumonia, or COPD. Health Care Management Science, 18(1), 19-
34. https://doi.org/10.1007/s10729-014-9278-y
Snyder, E. M., Van Iterson, E. H., & Olson, T. P. (2015). Clinical Classification of Heart Failure
Patients Using Cardiac Function during Exercise. Exercise and Sport Sciences
Reviews, 43(4), 204-213. https://doi.org/10.1249/jes.0000000000000061
Two types of heart failure. (2015). Focus on Healthy Aging, 18(1), 6.
U.S. Department of Health & Human Services. (2019, December 9). Heart Failure. Centers for
Disease Control and Prevention. https://www.cdc.gov/heartdisease/heart_failure.htm
