Heart Failure

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Product Overview

The Heart Failure Advanced Application is aimed at Cardiovascular Clinical Program directors, operational directors, clinical program guidance teams, operational guidance teams and care management teams. The application focuses on providing data for a health care system’s heart failure cohort. It aids in tracking and reporting CMS Core Measures (LOS, readmissions, administration of appropriate medications, etc.), risk stratifies patients requiring the most resources, and tracks care transitions to the outpatient arena. The data surfaced in this application helps identify opportunities for improving care and outcomes in all these areas.

Features

  • Executive Dashboard: Surveys high-level metrics such as LOS, mortality rate, readmissions rates, cost/case, etc. and shows how results are tracking toward system goals.
  • Risk Stratification Dashboard: Repeatedly (every 24 hours) stratifies hospitalized heart failure patients into groups of risk for readmission
  • Outcome Metrics Dashboard: Tracks LOS, mortality rates, readmission rates and cost per case.
  • Process Metrics Dashboard: Tracks identification and treatment modalities of heart failure patients; allows users to filter on ejection fraction, NYHA classifications, ICD counseling, or medications prescribed.
  • Transitions Dashboard: Tracks medication reconciliation, follow-up appointment scheduling, follow-up telephone calls, referrals to heart failure clinics, and other activities related to transitions in care.

Benefits

Benefits Include:

  • Increased ability to identify high-risk heart failure patients (those most likely to be readmitted within 30 days) and to provide appropriate interventions to prevent these readmissions.
  • Decreased 30- and 60-day readmission rates due to better tracking and improved transitions of care (medication reconciliation, follow-up visits within 48 hours, follow-up telephone call, and primary care provider knowledge transfer).
  • Increase compliance with CMS-recommended medications for treatment of the heart failure patients.

Measures

Available Measures Include:

  • Readmissions (30 or 90 day) – Percentage of patients with primary diagnosis of heart failure readmitted within 30/90 days of discharge. Readmission must be inpatient, non-elective.
  • Readmission LOS (Length of Stay) – The days between the readmit date and readmit discharge date.
  • ER Utilization – Primary HF discharged patients who came back to ER without any inpatient visits in-between. The days between the HF discharge and ER visits are calculated as well as ER LOS.
  • Observation Stay – Primary HF discharge patients who came back as OB patients without any inpatient visits in-between. The days between the HF discharge and the OB visit are calculated s well as the OB LOS.

See Sample Screenshots of Heart Failure

Data Sources

  • EMR
  • Patient Satisfaction
  • Billing Data

Heart Failure: A Deeper View

Background

Heart failure (HF) ranks as one of the most expensive inpatient diagnoses in the United States—and experts predict that costs will continue to rise in the decades to come. To help manage costs and patient health risk, CMS has elected to tie reimbursement to HF readmissions. Research shows that implementing numerous transitions of care will help lower readmission rates and promote increased satisfaction.

What types of problems does Heart Failure address?

To improve and manage care of patients with heart failure, it’s helpful to have a birds-eye view of key metrics associated with clinical best practice, high-level performance measures reportable to CMS, and transitions in patients’ care. It’s also valuable to be able to identify patients who would most benefit from the finite resources within a hospital system.

Use Cases

  • A hospital wants to see how readmission rates relate to their risk-stratification of heart failure patients.
  • A hospital’s executive team identifies the need to lower LOS of heart failure patients without increasing readmission rates.
  • A cardiovascular clinical program wants to understand if sending NYHA Classification III and IV patients to a nurse practitioner-run heart failure clinic will lower readmissions and improve patient satisfaction.

Anticipated Improvements

  1. Increased ability to identify high-risk heart failure patients (those most likely to be readmitted within 30 days) and to provide appropriate interventions to prevent these readmissions.
  2. Decreased 30- and 60-day readmission rates due to better tracking and improved transitions of care (medication reconciliation, follow-up visits within 48 hours, follow-up telephone call, and primary care provider knowledge transfer).
  3. Increase compliance with CMS-recommended medications for treatment of the heart failure patients.

Success Measure Examples

There are 3 types of success measures:

Opportunity Identification:

  • Potential $ saved from reduction in clinical variation and standardization of care.

Process Improvements:

  • Increase compliance with recommended practices for patient follow-up by X%.

Outcomes Improvement:

  • Reduce readmissions; reduce mortality; reduce LOS; reduce cost per case; improve patient satisfaction.