CHF Care

Transitional care features involved APNs, lowers hospital readmits

by Marlene Piturro, PhD, MBA

As payers energetically seek to lower costs and improve care quality for the most vulnerable elderly--those with multiple comorbidities and complex treatment schedules--adjusting staff and other resources to do so remains a major obstacle. Transitional care models offer new ways to deal with the frail elderly, thereby reducing high rehospitalization rates and other poor post-discharge outcomes.

Transitional care manages the sickest elderly patients: those cycling repeatedly between hospital and long-term care facilities. Although transitional care involves patients with multiple diseases, those with heart failure have proven particularly challenging and have the highest hospitalization rate of adult patient groups.

Central to the transitional care model is the advanced practice nurse (APN), who uses his or her clinical and managerial skills to formulate and execute comprehensive treatment plans.

Background

In health care necessity is often the mother of invention, as is the case with transitional care. As hospital stays shortened during the 1980s elderly patients (along with everyone else) were discharged quickly from hospitals, often leaving unresolved the clinical and psychosocial issues that brought them to the hospital in the first place.

At that time Mary Naylor, PhD, RN, the Marian S. Ware Professor in Gerontology at the University of Pennsylvania Health System, Philadelphia, saw a need to stop these frail elderly from falling through the cracks. So she began a two-decade quest to improve outcomes for the sickest elderly.

Early on, her multidisciplinary team at the University of Pennsylvania identified factors that led to breakdowns in care between hospital and long-term care settings (see "Transitional Care's Goal," at right).

Naylor's team built a transitional care model to improve results. In a series of studies evaluating the effects of different interventions on costs and outcomes, strategies to address patient and caregiver needs, and care coordination across settings, team members set out to address the needs of the elderly at high risk for rehospitalization and emergency department visits.

Naylor's early studies of elderly patients hospitalized for medical or surgical treatment of cardiac conditions showed that transitional care support by APNs in the form of intense discharge planning, phone calls, and home visits had a positive effect in the first six weeks post-hospitalization, but a subsequent drop-off in clinical and cost improvements. They then gave high-risk patients (those who had a history of repeat hospitalizations) support via phone seven days a week and had the APN substitute for the visiting nurse.

For up to 24 weeks post-hospitalization, these steps resulted in the intervention group having fewer hospitalizations and hospital days than the control group. Even factoring in the cost of APN services, transitional care showed savings of $3,000 per patient over the 24-week study compared with standard care.

Targeting Heart Failure

With the early studies complete, it became clear that heart failure patients had the highest rates of hospitalization and length of stay. The APNs improved outcomes up to a point, but the interventions were not sufficiently targeted to help elders manage the disabling symptoms of heart failure and complex treatment regimens.

"We realized our patients didn't only have heart failure, they had COPD, diabetes, cognitive impairments," explained Naylor. "The heart failure patients were in poorer health generally and had poor self-management skills regarding diet and exercise. They really needed the clinical judgment of APNs to develop their treatment plans."

Brian Bixby, an APN who's been in the University of Pennsylvania heart failure program since 1998, exemplifies the commitment required of APNs to ensure the success of the program. With a caseload of nine to 12 patients, Bixby provides clinical and personal consistency to patients and caregivers while managing each patient's comorbidities and multiple medications.

"There is so much that we do," he said. "We develop rapport with the patient and caregivers, try to get their buy-in with the program, balance contradictory things such as the American Diabetes Association and the [American Heart Association] heart failure diets, and educate the home health aides on how to work with us."

Bixby also builds relationships with each patient's primary care physician, whom he describes as "the captain of the ship. We always communicate with the primary care physicians--who are split evenly between internists and cardiologists--that the patient is in one of our studies."

Managing medications is an essential part of the APN role. "We sort out multiple medications, work with physicians and pharmacists to streamline the medications, and reduce the number of copays, and get plastic pill planners so the patients take the medication correctly" explained Bixby.

For patients and spouses who may have visual and dexterity problems handling pills, Bixby relies on caregivers, such as home health aides, to assist in organizing and dispensing meds.

Using funds from the National Institutes of Health and other sources, Naylor's team systematically refined its research, culminating in the most recent study, a heart failure management program at six academic and community hospitals in the Philadelphia area.

Of 239 heart failure patients randomized between intervention and control groups, those who received APN care had significantly lower readmission rates and improved patient satisfaction and quality of life after one year (see "The UP Transitional Care Program 2004 Results," at right).

Other Venues

Even without the support of an academic medical center, the potential for transitional care is recognized elsewhere. Nancy Bonnet, clinical nurse specialist at the Mountainside Hospital Heart Failure Program in Montclair, N.J., saw her patients moving repeatedly between the 290-bed community hospital and home or nursing facilities. In 1998 she decided to do something about it, even though the odds were against her because she worked in a community hospital rather than an academic medical center.

After visiting heart failure programs with transitional care features at Tulane University Health Systems (New Orleans), St. Vincent's Medical Center (Bridgeport, Conn.), Hackensack University Medical Center (N.J.), and Columbia Presbyterian Hospital (New York) she built a program with outpatient and long-term care components.

Because her hospital had no medical director, Bonnet's efforts to establish a heart failure program proved even more difficult. She had to rely on primary care physicians to refer their heart failure patients--the "bread and butter of their practices," she noted.

Because the physicians were reluctant to refer patients, Bonnet asked them for "their worst pains in the butt." Finally one physician, an invasive cardiologist, saw the value of the program and referred his patients. By 2003, 15 doctors had followed suit.

The HomMed Health Monitoring System, which allows APNs to monitor each patient's heart rate, blood pressure, weight, oxygen saturation, and other indicators by telemetry, has been essential to Mountainside's success.

In a 2002 survey by Strategic Healthcare Programs, LLC, of New York Heart Association Class III and Class IV CHF HomMed patients versus a control group, those with HomMed telemonitors reduced congestive heart failure-related hospitalizations by 65.9% and emergency department visits by 61.7%.

Close ties to caregivers, adherence to collaboratively developed guidelines, and detailed discharge planning are other successful Mountainside program components. The results are encouraging: In tracking 150 patients, the Mountainside readmission rate dropped from 70% to 30% in two years. Bonnet says their length of stay is still too high at 7.8 days, however. The Mountainside Hospital 18-bed skilled nursing facility helps lower length of stay. The APNs work intensively with physical and occupational therapists to return heart failure patients back to their long-term care settings quickly.

"Our multidisciplinary team members see what has to be done to transition the heart failure patient from hospital to skilled nursing facility, home, or nursing home," said Bonnet. "We've reduced readmission rates dramatically, but numbers don't tell the whole story. Fewer readmissions mean avoiding those 3 a.m. calls to the cardiologist that result in rehospitalizations."

A new weapon in the Mountainside program: inclusion of patients in Phase II trials of nesiritide (Natrecor), a weekly infusion in outpatient settings. In Phase I trials nesiritide showed improvements in clinical status and fewer rehospitalizations than standard treatments.

The Money

Because Medicare doesn't customarily pay for case management services, making a transitional care program solvent takes effort. "The APNs can bill for many services," noted Bonnet, "such as full outpatient assessment at 85% of the physician's rate, CBT Level 4 visits, home visits, facility fees, and some educational visits."

Sanford Schwartz, MD, health-care economist at the University of Pennsylvania Medical School, faults the misaligned incentives of the Medicare reimbursement system for "giving providers powerful motivation to do only what they get paid for. Care management programs such as ours add real costs to the system," he explained. "Eventually, the system will change as payers realize that we're not only delaying, but often avoiding rehospitalizations."

For Naylor the end game is for the Centers for Medicare and Medicaid Services to change its policy on reimbursing for care coordination. "Our job is to translate the science from our research projects into easily adaptable programs for health plans and other payers," she concluded. With a major insurer ready to roll out a customized version of the University of Pennsylvania program, Naylor seems well on her way toward achieving that goal.

Conclusion

With a health-care system constantly seeking new ways to reduce inpatient hospital stays and emergency department usage for the frail elderly, providers should remain mindful of what happens to seniors as they transition between in-patient and long-term care settings.

Transitional care models, based on close collaboration between primary care physicians and APNs to ensure that the most vulnerable seniors don't fall through the cracks, offer the kind of exciting innovations that our healthcare system needs so badly.

Marlene Piturro has been a contributing writer for Caring for five years.

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