Heart failure (HF) care programs frequently are disjointed and uncoordinated, resulting in higher hospital readmissions and longer length of stay. To prevent unnecessary readmissions, staff at the Baylor Medical Center Garland (BMCG) in Garland, Texas, studied the effectiveness of a nurse-led transitional care pilot program designed to synchronize management for this patient population and help avoid readmissions. The program did just that by reducing 30-day HF readmissions almost 50 percent. While programs such as these achieve quality outcomes, they may not be cost-effective.
Choosing the right pilot
Research has shown that HF readmission rates range between 10 to 19 percent two weeks after discharge and skyrocket to nearly 50 percent within three months of discharge (Arch Intern Med 2011:171;1238-1243). U.S. hospital readmissions contributed to the $33 billion bill for HF costs in 2006 alone.
Due to the 23 percent readmission rate at BMCG, a high-volume hospital that sees approximately 300 HF admissions per year, staff at Baylor searched for a cost-effective, practical transitional care model to curb the potentially preventable obstacle.
"We were not at our desired level as a health system so we needed a different approach," says Brett D. Stauffer, MD, of the internal medicine/hospitalist department at the Baylor Health Care Center in Dallas. "To do so, we began looking at different care models to help reduce hospital readmission rates."
After much searching and planning, staff at BMCG, a 263-bed hospital, decided to test an Advanced Practice Nurse (APN)-led transitional care program in an attempt to reduce 30-day readmission rates, costs and length of stay. If the pilot worked, the system might later roll out the program to the rest of the 27-hospital system.
The intervention consisted of a three-month APN-led transitional care program where the initial APN home visit occurred within 72 hours of the index hospital admission. In addition to a full-time APN, the program had to be run in conjunction with a licensed physician to oversee the APN's work. (According to Texas law, APNs cannot act independently.) The study population included 140 Medicare HF patients who were 65 years or older and discharged from BMCG between Aug. 24, 2009, and April 30, 2010.
Along with overseeing the APN, the licensed physician managed back office billing and support for documentation in the EHR. The program, implemented in collaboration with the HealthTexas Provider Network, also required remote access equipment to facilitate house calls and hospital-to-home transition of care.
However, even more important than hardware and software was finding a dedicated group of staff—nurse practitioners, physicians and administrative staff—to make transitional care models such as this one work, Stauffer says. "The success of our program had the most to do with the staff who ran the project."
The $1 million question: What will it cost?
While the hospital realized a 48 percent drop in 30-day HF readmission rates, the impact of the program on length of stay and 60-day direct costs was rather minimal. Therefore, support from senior leadership is imperative to these programs because while they help patients, says Stauffer, they also may not be profitable.
Stauffer says that the facility realized a cost improvement after the first hospitalization because of a reduction in length of stay, but the overall system lost money. "Payors, whether Medicare or others, need to reimburse and support hospitals in a way that health systems can be rewarded for implementing these types of interventions," Stauffer says.
The costs are manageable with this program, says Neil S. Fleming, PhD, vice president and chief operating officer of the STEEEP (safe, timely, effective, efficient, equitable and patient-centered service) Global Institute at Baylor in Dallas, which disseminates best practices to external organizations. The fact that the hospital receives reimbursement for home visits offsets some of the direct costs of patient care.
"In addition, there are one-time fixed costs to set up this type of program," says Fleming. "Going forward, we will move past this initial phase when evaluating the impact the program has on the patient."
Ultimately, costs for each Medicare patient were reduced by $227 due to the dip in readmission rates seen with the program. "The first time you roll one of these programs out, it will always be more expensive," he says. This is why it