How do they do it? Baylor has lowest HF readmissions
Bad media drove medical center to the top
When the Centers for Medicare & Medicaid Services announced it would publicly report hospitals' readmission and mortality rates for heart failure, heart attack, and pneumonia, Baylor University Medical Center (BUMC) was front and center. According to a front-page article in USA Today, it had the lowest readmission rate for heart failure patients in U.S. hospitals at 15.9%. The next hospital was two percentage points away.
Pam Stafford, RN, BSN, CPHQ, health care improvement process consultant for the Baylor Healthcare System with headquarters in Dallas, says the work the system has done continues today. And its rates are the result of a multifaceted improvement process.
Where did Baylor begin?
The improvement process, Stafford says, began about two years ago when a very different article with a very different story ran. It was in a local paper, and it reported that one Baylor facility had one of the highest mortality rates in heart failure. The system decided to create a heart failure task force. Since its inception, Stafford says it has honed its action plan to four components:
- implementation and use of a standardized order set across the system;
- improving medication reconciliation;
- focusing on the transition, or continuity, of care;
- rethinking palliative care of end-of-life issues.
Using an order set
In adopting a bundle for heart failure care, Stafford says, the team made sure all components were best of, or evidence-based, care on issues including angiotensin-converting enzyme inhibitors (ACE) and angiotensin II receptor blockers (ARB) and discharge instructions. It took some elements from the Institute for Healthcare Improvement's 5 Million Lives Campaign to ensure that all HF patients had the appropriate vaccines, anticoagulants, and beta-blockers as appropriate. (Editor's note: The Centers for Medicare & Medicaid Services and The Joint Commission removed the AMI-6 measure, which required heart patients to receive beta blockers on arrival, effective for discharges after April 1, 2009.)
The set includes checkboxes that are already checked for mandatory elements, and then spaces to write in, for optional things such as which drug to order. To track compliance, for any patient who falls into Baylor's core measure population for heart failure, data are entered into an electronic medical record system, and one piece is whether the order set is used. "It's been difficult to get doctors to buy in. So we spend a lot of time on promoting the use of that order set," she says. Systemwide, compliance is at 70%. In some facilities, it's 100%.
"I think one of our strengths is physician champions," Stafford says. Each facility within the system has a heart failure physician champion. "And if you're running into barriers or having particular problems with one group of physicians or one physician, they talk peer to peer. The physician goes and talks to the other physician about order set use," she says. The champion prompts the physician by asking: What keeps you from using it? That face-to-face interaction has made a difference, she says; it's not health care improvement staff holding physicians accountable, but the physicians champions and senior leadership.
Monthly data are disseminated showing a run chart of each facility's order set use. Health care improvement directors and physician champions receive the unblinded data down to the individual physician level — who's complying and who's not. The system has just begun to post that information in the hospital in areas such as hospitalists' offices, physician dining rooms, or physician lounges.
BUMC and the Baylor Heart and Vascular Hospital have the lowest HF readmission rates, respectively, among the hospitals in the system. Both hospitals can refer patients to their outpatient heart failure clinic, which has a 3-4% readmission rate. Stafford attributes the low rate to the individualized care patients can get there. "The things we teach [the patients] when they're inpatients are actually getting followed as an outpatient," she says. Medications, diet, weight can all be monitored and, if any problems arise, can be dealt with immediately before that patient would elect to go back to the hospital.
Transition of care pilot
Another thing one of the facilities is doing is piloting the transitional care model developed by Mary Naylor in which an advanced practice nurse sees patients first on the inpatient side, then follows them at home, seeing them within 24 hours of discharge and then for three more months.
In the hospital, the APN sees patients Monday, Tuesday, Thursday, and Friday and then chooses one weekend day to check on patients still in the hospital. Stafford points out that this isn't a cost-prohibitive model. Since the particular APN at this community hospital has been in that line of work for about a dozen years, not much money had to be expended on training. She handles all the patients for the hospital.
Addressing end-of-life issues
One day Stafford looked through patient charts to find out who exactly is being readmitted. One of the first charts she looked at was that of a 95-year-old man who lived in a nursing home. He had been readmitted seven times in one year and eventually died in the hospital. "Someone needed to talk to that family and that patient long before than seventh readmission," she says.
One particular hospital in the system has an older patient population and was noticing, in essence, that the local "nursing homes send patients to [this] hospital to die," Stafford says. The facility worked with the nursing homes that admitted the most patients, educating them on palliative care and hospice. "They were able to affect the inpatient mortality and readmission rate because they were working on those end-of-life issues," she says.
Part of the system's action plan deals with palliative and end-of-life care, with the instruction "to not admit inappropriate patients," Stafford says. "Don't admit patients who really should be on some sort of end-of-life care plan."
It's a subject people don't want to talk about, especially physicians, who are not taught how to discuss end-of-life issues with patients. Stafford says many cardiologists and internists have come to her addressing their concern with broaching the topic with patients and their families.
The system has palliative care teams to help the physicians educate patients about their options when they are nearing end of life. Nurses use a screening tool for advanced heart failure patients to address risk. Depending on the score, the checklist instructs the nurse to:
- talk to the physician about patient needs such as controlling symptoms, referral to disease management, or advance care planning; continue to monitor and reassess weekly;
- suggest palliative care consult;
- ask the physician to strongly consider palliative care consult.
Physicians "know there's a team and a palliative care doctor that could come and either talk to them or the patient — someone that's comfortable and knowledgeable in end-of-life issues and talking to patients. And if [patients] need palliative care or hospice, that's what we need to do rather than continue readmitting them until they die in the hospital," Stafford says.
She says there is not one single thing she can point to for the success the hospital has had with readmission rates. But, she says, "what is starting to be obvious is that heart failure care is a bundle much like ventilator-associated pneumonia or central-line infections. That care is a bundle. You can't just do one thing and expect it to improve. You can't just use discharge instructions or just do one component of the medications or one piece of transitional care. It has to be all of it, and you have to be working on all of that at the same time."
When the Centers for Medicare & Medicaid Services announced it would publicly report hospitals' readmission and mortality rates for heart failure, heart attack, and pneumonia, Baylor University Medical Center (BUMC) was front and center.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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