By Melinda Young
Case management and care coordination programs that target heart failure patients with low socioeconomic positions (SEP) can succeed in improving their outcomes, but it takes time and consistent effort across the continuum.
Thanks to better treatment, people with heart failure are living longer in the United States. This phenomenon has resulted in more people with heart failure admitted to the hospital — which, in turn, has led to greater strain on the healthcare system, according to the authors of a recent paper.1
The next step is to improve care management and care coordination through targeted, consistent, and persistent efforts.
“Heart failure, elective surgeries, sepsis, and infections are big things where people are readmitted,” says Sydney E. Browder, lead author of the paper and a PhD candidate with the Gillings School of Global Health at the University of North Carolina at Chapel Hill.
Readmissions are more likely among people with low SEP. This suggests that when resources are limited, patients with low SEP should be prioritized in care coordination and case management efforts. “Everyone has to be on board to reduce these readmissions,” Browder says.
Preventing heart failure and other chronic diseases would be the ideal solution. But when case managers first meet patients with these conditions in the hospital, that is where their intervention must start.
“Showing up and meeting patients when they’re in the hospital can be really valuable,” Browder says. “After they’re discharged, they’ll be more likely to answer your follow-up phone call if you had showed up while they were hospitalized.”
Patients often feel as though they are forgotten by the system, so any physical presence and overt care by case managers can show them they are valued. It also may lead to patients following their care management plan.
“How would you want to be motivated to do these things? Support from people who know the system helps,” Browder says. “For people who are patient-facing and interact with these patients, remember it’s a privilege to be there, and you’re making a difference. We need support for our staff in hospitals because no one can do it alone, and we all deserve support.”
Browder and colleagues studied which interventions have worked and theorized on interventions that have not yet been tried or studied.
The Hospital Readmission Reduction Program (HRRP), established in 2012 by the Affordable Care Act, was designed to mitigate heart failure readmissions and costs. It penalizes hospitals that record higher-than-expected risk-standardized 30-day readmission rates for acute myocardial infarction, pneumonia, COPD, elective hip and knee replacement, coronary artery bypass graft, or heart failure.1
In efforts to avoid penalties, hospitals have started transitional care interventions that focus on discharge planning, post-discharge follow-up programs, patient education, and improving medication adherence. They also have focused on social determinants of health, particularly for low SEP patients.1
“HRRP looks at where our money is spent across the healthcare system and admissions,” Browder says.
One potential flaw in HRRP is that it does not consider the percentage of low SEPs in each hospital. “They didn’t even include the socioeconomic position in the model of the program, which is a big flaw,” Browder says. “If a hospital is above a threshold, then there should be differences in penalties. If people are readmitted due to circumstances beyond the hospital’s control, they should not be penalized.”
Data suggest that HRRP might be unintentionally penalizing hospitals that care for disadvantaged populations and adding to the healthcare access barriers of these populations.1 For example, a rural hospital may incur more penalties under HRRP because they see a higher percentage of low-income and low-SEP patients. This creates a cyclical problem of the hospital trying to create interventions to help patients, but the hospital is penalized, which results in fewer resources for starting interventions that could prevent these patients from returning to the hospital.
“We structured our review as prehospitalization and post-hospitalization phases,” Browder says.
The prehospitalization phase includes the patient’s social determinants of health, such as education, healthcare access, and community support, and it covers their entire life. Barriers can be personal, situational, and systemic. For example, a systemic barrier could be that someone grew up in a large city and did not have access to green spaces. As such, they did not exercise as much as they would have if they had access to healthy and safe places to walk. This population also is exposed to air pollution, which can affect their health.
Another barrier is found in rural areas where people live far from the nearest hospital and have too few family care providers. This makes it less likely people will seek disease management care, especially in the early stages when there are few symptoms.
“They are less likely to go and may present at the hospital with more advanced disease,” Browder says. “We need more policy changes, and there is also the larger issue of structural racism and how we can achieve equity.”
Barriers related to the hospital could involve having case management staff to help patients bridge gaps in care and to help patients with disease management.
“Do you have full-time staff on your side, looking out for the best interest of the patient? Do you have pharmacists, physicians, case managers, hospital administrators, and nurses on your side? Are they all on the same page?” Browder asks. “This camaraderie of wanting to work for the best interest of patients has been shown overall to improve health, regardless of the disease.”
Another intervention is to reduce the patient’s medication burden. Case managers can provide good care instructions at discharge, but if a patient has 20 different medications to take daily, they may face challenges. One solution may be for the provider and pharmacist to find a way to cut their medication regimen to four or five. This helps set a patient up for success.
In the post-hospital phase, the goal may be to ensure patients follow up on medical appointments and take their medication.
“Those are the two most important parts of preventing rehospitalization,” Browder explains. “Have patients go to their doctors’ appointments and take their medication.”
Automated care management tactics, such as text message reminders for appointments, can help. Telehealth is another method.
“Telehealth has exploded in terms of being able to reach people who live far from hospitals or who may not have reliable transportation,” Browder says. “In the two weeks after hospitalization, are patients coming back to the hospital or to a clinic visit? If something is wrong, it will be caught more often at that stage.”
Patients who skip their early post-hospitalization visit or who never schedule one are more likely to struggle after their discharge. It makes sense to incentivize them to show up or to help them eliminate transportation and other barriers to attending their follow-up visits.
“Telehealth is a great intervention for this population to meet with a physician over some sort of interface,” Browder says.
Caregiver support is essential in all phases. Patients report better outcomes if they receive reliable caregiver support from family and friends. Caregivers can remind them to take their medication and can drive them to the hospital or physician’s office.
“Heart failure is a long-haul disease; mortality rates are declining, but more patients are living with heart failure and are progressing in their disease,” Browder explains. “Caregivers can take care of their loved ones for years, which can ultimately take a toll if they’re not taking care of themselves.”
It may work best if there were cohesive solutions and answers to these health management barriers. But there are no solutions across state and city lines.
“Every hospital is trying their own techniques,” Browder notes. “A rural hospital may have different needs than an urban hospital.”
Decades of care management and coordination data have produced recommendations that hospitals and case managers can follow. The drawback is these solutions often are expensive and require hospitals to hire multiple healthcare workers to implement them.
Another drawback is that hospitals and healthcare professionals are accustomed to looking at solutions for individual patients undergoing a procedure or treatment for their illness. They may not think about studying this from a population level and thinking about a patient’s social needs and how these affect the patient’s ability to manage their disease.
“We are not just seeing their wound and amputation need but also should see how they got this illness in the first place and how they were allowed to fly under the radar to where their disease progressed to this extent,” Browder says. “Everyone needs to think outside of the immediate problem. How we prevent them from even getting there in the first place is a conversation we need to have.”
This could include things like dental care. Dental infections are a cause of larger infections and could lead to cardiovascular diseases, Browder adds. Patients with heart failure also may not be taking care of their heart by adhering to a healthy diet and regular exercise. “There is a cascade of patients who are sick — and not typically sick from only one disease,” Browder says. “They may have three to five diseases like diabetes, high blood pressure — all of which almost always end up in some form of cardiovascular disease.”
Mental healthcare also is a big part of taking care of the whole person and the whole population. “The idea of taking care of your mental health as much as your physical health is important,” Browder says. “Get people the care they need for anxiety, depression, and stress.”
It is part of the idea of looking out for patients’ mind, body, and spirit. It is challenging and requires a lot of money and large-scale policy changes, but it also is a goal, she adds.
“It’s saying, ‘Yes, we want to treat everyone and give them an opportunity to get the best care possible,’” Browder says.
REFERENCE
- Browder SE, Rosamond WD. Preventing heart failure readmission in patients with low socioeconomic position. Curr Cardiol Rep 2023; Sep 26. doi: 10.1007/s11886-023-01960-0. [Online ahead of print].
Case management and care coordination programs that target heart failure patients with low socioeconomic positions can succeed in improving their outcomes, but it takes time and consistent effort across the continuum. The next step is to improve care management and care coordination through targeted, consistent, and persistent efforts.
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