On October 1, as part of the implementation of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) will reduce payments to Inpatient Prospective Payment System (IPPS) hospitals that have been determined to have excess readmissions based on readmission rates for acute myocardial infarction, heart failure and pneumonia.Under the new payment structure, a readmission will be determined to occur when a patient is discharged from an IPPS hospital and then re-admitted to the same or another IPPS hospital within 30 days of discharge.
Congestive heart failure (CHF) accounts for more than $8 billion in annual Medicare expenditures 
alone. Creating CHF disease management programs that provide patient education, identify social support for the patient and provide off-site clinical support such as telemedicine may reduce the risk of patient hospitalization.
alone. Creating CHF disease management programs that provide patient education, identify social support for the patient and provide off-site clinical support such as telemedicine may reduce the risk of patient hospitalization.Eight months ago, Holy Cross Hospital in Fort Lauderdale opened the Heart Failure Clinic. For the first five months of this year, the national average for heart failure 30-day readmission rates was 24.5 percent. During that same period, of the 90 patients who had been discharged from Holy Cross into a care program in the clinic, only one was readmitted within 30 days, which shows a 2% readmission rate for the Heart Failure Clinic.
The clinic provides support that helps reduce readmissions in the following seven areas:
Risk assessment: A patient’s first visit to the clinic is usually 90 minutes as we perform a thorough risk assessment and discuss the patient’s condition. This may include the Minnesota Living with Heart Failure questionnaire or the Seattle Heart Failure Model as well as a six-minute walking test and cardiopulmonary exercise testing.
Liaison care: It is important for physicians to realize that physician extenders such as nurse practitioners or physician assistants can play an important role in care programs and provide an alternative to patients seeking care in the ER. The clinic works with the referring physician on a cardiac rehabilitation plan. One of our goals is to have the clinic offer acute care where, for example, a physician could send a CHF patient who is presenting with shortness of breath to be treated and monitored for a day.
Pharmacotherapy: Utilizing feedback from the referring physician, the clinic works to identify evidence-based optimal medical therapy and diuretic management.
Telemedicine: One of the most important aspects of CHF disease management is keeping in contact with patients with regular phone calls and monitoring high risk, homebound patients. This support area also includes communication with any out-of-hospital team.
Education: From teaching patients how to read nutritional labels on food and properly take medications to monitoring weight, diet and exercise, patient education plays a major role in reducing hospital readmissions. Ensuring patients truly understand their responsibilities toward their treatment requires one-on-one caregiving, which takes time and is better suited to a disease management program clinic rather than a physician office visit.
Social support: There may be gaps in patient care after discharge. The clinic helps provide educational resources and identify support in the community such as family members and nursing homes. Coordinating home health for high-risk patients can also serve to reduce ER visits.
Life saving therapies: Successful CHF disease management programs also expose the patient to different therapies and technologies. For example, high-level functioning CHF programs allow patients to participate in clinical research trials while patients who have advanced CHF may gain the ability to receive life changing therapies such as ventricular assist devices.
The number of hospital discharges in which CHF was the first listed diagnosis in 1993 was almost five times greater than it was 25 years earlier. This trend will continue given an aging population, the simple fact that more patients are surviving their initial cardiac event and that people are living longer with chronic diseases such as diabetes, kidney disease and hypertension and are at increased risk of developing CHF.
Better systems such as CHF disease management programs are needed to improve outcomes and reduce costs.
