Prevention of Heart Failure Hospital Readmissions Presentation

Abstract

• Heart failure (HF) is incurable.
• Affects over 5 million people.
• Costs 1.7 billion dollars annually.
• High rates of readmissions: complex care.
• Inadequate patient education.
• High incidence among African Americans.
• Interventions aimed at reducing readmissions.
• Implementation of a specialized nurse case manager.

Introduction

• Heart failure:
  • Serious health concern.
  • High prevalence among aging population.
• Complex management: affects 5 million people.
• High hospital readmission rates.
• In 2006:
  • More than 1 million admissions.
  • 24.2% readmitted within a month.
• Higher prevalence among African Americans: 50%.
• Prevalence differences:
  • The elderly between 75 and 84 years.
  • 20% more black men.
  • 27% more black women.
• Possibility of development higher in younger people:
  • Risk 20 times higher among African Americans.
  • Higher mortality rates.
  • 45% greater death risk among African Americans.
• Improvement of patient care imperative.
• Areas of focus:
  • Anatomical/physiological/epidemiological issues.
  • Analytical questions of healthcare costs.
  • Prevalence among populations.
  • Causes of care disparity.

Structure of the Heart

• Heart plays many functions:
  • Pumps blood to cells.
  • Provide energy, nourishment, and normal functioning.
• 4 chambers: atria and ventricles.
• Atria: upper chambers.
• Ventricles: lower chambers.
• Heart function involves organized contractions.

Heart Failure Definition

• Heart failure: weak muscles malfunction.
• Functional, structural or biological impairment.
• Heart’s inability to deliver adequate blood.
• Symptoms of HF:
  • Fatigue.
  • Water retention.
  • Edema.
  • Shortness of breath.
  • Exercise intolerance.
  • Fluid retention.

Diagnosis

• A difficult process.
• Involves clinical diagnosis and examination.
• HF:
  • impairment of systolic ventricular function.
  • Damage to heart valves or pericardium.
• Stages of heart failure:
  • Stage A: high risk.
  • Stage B: structural heart abnormalities.
  • Stage C:abromalities and symptoms.
  • Stage D: symptoms resistant to treatment.

Risk Factors

• Double risk among African Americans.
• Cause of higher prevalence:
  • Inadequate education.
  • Financial strain.
  • Inadequate housing.
  • Lower annual incomes.
• Lack of primary care providers.
• Poor insurance status.
• Disparity in delivery and access to care.
• History of hypertension, obesity, and diabetes.
• Racial and ethnic equality in clinical trials.

Living with Heart Failure

• Heart failure is incurable.
• Impaired functioning, medical crises, and hospitalizations.
• Functional losses and increased dependency.
• Increased difficulty of management.
• Successful treatment involves cooperation.
• AHA treatment recommendations:
  • Lifestyle changes:
    • Diet modification.
    • Alcohol avoidance.
    • Cessation of tobacco use.
  • Medical management: pharmaceuticals.
  • Implantable medical devices.

Heart Failure Cost

• Highest HF readmissions.
• Largest total cost: $1.7 billion.
• CMS penalty: $428 million.
• HF readmission cases:
  • Health care quality challenge.
  • Health care cost issue.
• Utility of treatment: tension regarding HF:
  • Chronic deteriorating condition.
  • Terminal illness.
• Aggressive care is more costly.
• Medical management: 10 medications.
• Advanced technologies.
• WHO recommendation:
• Early palliative care.
• The NMAHFCP 2013 findings:
  • African Americans ignore treatment guidelines.
  • Need to track HF disparities.
• Mitigation of health care inequality.
• Equality critical for medical decisions.

Change from Traditional Inpatient Care

• HF care is complex.
• Traditional inpatient care processes are inadequate.
• Post-discharge needs ignored.
• Minimal patient teaching.
• High readmissions signify ineffective methods.
• Shift focus to long-term outcomes.
• Emphasis on self-care management.
• Implementation of nurse case managers.
• HF case management:
  • Patient’s physician.
  • Physical therapist.
  • Dietician.
  • Pharmacist.
  • Cardiologist.
  • Social worker.
• A multidisciplinary approach.
• Individualized treatment.

Inpatient Education

• Implemented by nurse case manager.
• Conducted throughout hospitalization and discharge.
• Enhanced communication with health care team.
• Medication teaching:
  • Reduces readmission rates.
  • Compliance with medications.
  • Improved clinical outcomes.
• Patient understanding of medication regimen.

Implantable Devices

• Implantable cardio defibrillators prolong survival.
• Implantable devices benefits:
  • 37% reduction in hospitalizations.
  • 60% drop in patient mortality.
  • The use of less medication.
• Risk involvement.
• Individualized disease management.

Diet

• Appropriate diet and nutrition education.
• Diet indiscretions worsens HF.
• A low sodium diet.
• Western diet is a challenge.
• Control of intravascular fluid volume.

Lifestyle Changes

• Lifestyle improvement education.
• Abstinence or avoidance of alcohol:
  • Induced cardiomyopathy.
• Controlled fluid intake:
  • 1.5-2.0 liters daily.
  • Relieve symptoms of congestion.
• Involvement in regular exercise:
  • Emotional well being.
  • Increase breathing capacity.
• Smoking cessation:
  • Decrease breathlessness.

Discharge Planning

• 30-90 days post-discharge critical.
• Impact of Cognitive and social issues.
• Follow up appointment reduces readmission.
• Clear medication regimen instructions.
• Communication:
  • 48 hours after discharge.
  • Biweekly for 3 months after discharge.
• Education of care providers.
• Importance of home support.

Follow up Care: Patient Education

• Importance of checking daily weight.
  • Signs of excessive weight gain.
  • Risks of kidney failure.
• Home health nurse visits:
  • Verification of patient medication adherence.
  • Weight patterns.
• Importance of individualized treatment plans.
• Public health model for African Americans:
  • Health education.
  • Primary prevention.
  • Risk assessment.
  • Improved access to care.
  • Use evidence-based therapies.
• Fulfillment of patients’ essential needs:
  • Income concerns.
  • Adequate housing.
  • Access to medications.

Conclusion

• HF is costly to the healthcare system.
• Care aggressiveness creates tension.
• How should HF be classified?
  • A chronic deteriorating disease.
  • A terminal illness.
• Need for racial and ethnic equality.
• Health care reforms.
• Importance of medical management.
• Education and coordination of patient care.
• The roles of specialized HF nurse care managers:
  • Patient/caregiver disease education.
  • Medication compliance.
  • Clos follow up.
  • Patient callbacks.
• Reduction of readmissions:
  • Intensive inpatient education.
  • Discharge planning.
  • Follow up care.
• Quality improvement programs.

References

American Heart Association (2018). About Heart Failure. Web.

Brake, R., & Jones, I. (2017). Chronic heart failure part 2: Treatment and management. Nursing Standard (royal College of Nursing (Great Britain): 1987,31(20), 53-63. doi:10.7748/ns.2017.e10762

Chandrasekaran, B., & Cowburn, P. (2010). Heart failure: The challenge of selecting patients for implantable cardioverter defibrillator therapy. Expert Review of Medical Devices,7(4), 461-7. doi:10.1586/erd.10.18

David, D., Howard, E., Dalton, J., & Britting, L. (2018). Self-care in heart failure hospital discharge instructions— differences between nurse practitioner and physician providers. The Journal for Nurse Practitioners,14(1), 18-25. doi:10.1016/j.nurpra.2017.09.013

DeFelice, P., Masucci, M., McLoughlin, J., Salvatore, S., Shane, M., & Wong, D. (2010). Congestive heart failure: redefining health care nursing. Journal of Continuing Education in Nursing, 41(9), 390-1. Retrieved from CINAHL Plus with Full Text Database.

Fleming, L., Gavin, M., Piatkowski, G., Chang, J., & Mukamal, K. (2014). Derivation and validation of a 30-day heart failure readmission model. The American Journal of Cardiology, 114(9), 1379-82. doi:10.1016/j.amjcard.2014.07.071

Gardenier, D., Valles-Gutierrez, L., & Ballard-Hernandez, J. (2018). Do discharge instructions make a difference in patients with heart failure? The Journal for Nurse Practitioners,14(10), 708-709. doi:10.1016/j.nurpra.2018.07.001

Glippatos, G., & Zannad, F. (2007). An introduction to acute heart failure syndromes: Definition and classification. Heart Failure Reviews,12(2), 87-90. doi:10.1007/s10741-007-9008-3

Mitchell, J. E., Ferdinand, K. C., Watson, K. E., Wenger, N. K., Watkins, L. O., Flack, J. M., . . . Wright, J. T. (2011). Treatment of heart failure in African Americans— A call to action. Journal of the National Medical Association, 103(2), 86-98. Web.

Panagiotis Georgoulias. (2016). FRONTIERS IN HEART FAILURE : Frontiers in Heart Failure (volume 1). Bentham Science Publishers Ltd.

Rothberg, M., MD, MPH, & Sivalingam, S., MD. (2010). The new heart failure diet: Less salt restriction, more micronutrients. Journal of General Internal Medicine,25(10), 1136-1137. doi:10.1007/s11606-010-1254- 8

Schwarz, E. R., Philip, K. J., Simsir, S. A., Czer, L., Trento, A., Finder, S. G., & Cleenewerck, L. A. (2011). Maximal care considerations when treating patients with end-stage heart failure: Ethical and procedural quandaries in management of the very sick. Journal of Religion and Health, 50(4), 872-9.

Stocker, R., Close, H., Hancock, H., & Hungin, A. (2017). Should heart failure be regarded as a terminal illness requiring palliative care? A study of heart failure patients’, carers’ and clinicians’ understanding of heart failure prognosis and its management. Bmj Supportive & Palliative Care, 7(4), 464-469. doi:10.1136/bmjspcare-2016-0012

Vaccarino, V., Gahbauer, E., Kasl, S., Charpentier, P., Acampora, D., & Krumholz, H. (2002). Differences between African Americans and Whites in the outcome of heart failure: Evidence for a greater functional decline in African Americans. American Heart Journal,143(6), 1058-67.

Vidic, A., Chibnall, J. T., & Hauptman, P. J. (2015). Heart failure is a major contributor to hospital readmission penalties. Journal of cardiac failure, 21(2), 134-137.