Novel collaborative care program reduces HF readmission rates
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A chronic disease management pilot program designed to digitally connect health care providers and community-based agencies reduced HF readmission rates and improved communication among care team members, according to a case study.
The South Texas Physician Alliance (STPA), an independent physician association serving the Lower Rio Grande Valley, worked with health care communication company LeadingReach to digitally coordinate care for its Heart Failure Reduction Program. The 30-day program is initiated when the hospital sends a collaborative referral for a HF patient. Care team members use a digital platform for confirming appointments, communicating issues via a team chat function and sharing documents.
The program is designed to improve overall patient well-being; however, the STPA also observed an overall reduction in HF readmission rates as well as improved care coordination across agencies, according to Sheila Magoon, MD, executive director of STPA.
Healio spoke with Magoon and Curtis Gattis, CEO and co-founder of LeadingReach, about the importance of collaborative care in HF, getting ahead of patient challenges and plans to expand the program beyond HF.
Healio: Why was there a need for this type of program, specifically for HF?
Magoon: We have had readmission issues and high admission rates in our region for many years. This issue has always been on our radar, and we have been approaching it from a variety of different standpoints. When we looked at Medicare data for HF in particular, our readmission rates ran 22% to 23% in our region. This is something we need to figure out how to fix. We chose to focus on HF for several reasons. First, it is an outpatient treatable condition most of the time. Second, HF, unlike sepsis, which also has high readmission rates, is a condition that could be more amenable to a pilot program.
Gattis: Communication has been broken in health care. We are in the business of connecting communities digitally. If you look at a typical HF patient, this work has really opened our eyes to the team-based approach that is required for it. HF requires not just the primary care physicians and the cardiologists, but subspecialists — a HF specialist, HF nurse, imaging centers, case managers, pharmacists, physical therapists and home health agencies. It is a challenge in the urban areas, but once you get down into the Lower Rio Grande Valley and overlay the social determinants of health and other unique challenges, a program like this provides a great opportunity to move the needle in a big way. If we get ahead of these challenges, we can keep these patients healthier.
Healio: How did this program come together and how does it work?
Magoon: One of our larger hospitals came to us and said, ‘We have a readmission problem.’ We said, ‘So do we.’ They are all our same patients. So, how can we fix this? We were already working with LeadingReach in the classic physician-to-physician referrals. I have seen what it can do.
At the same time, local emergency medical services initiated a community paramedic program. The hospital administrator and I started building this program out. We created a plan where the hospital case manager would identify the patients with HF while they were still in-house, and then we designed what we call a collaborative referral. That referral goes to the community paramedic. It goes to our care transitions nurse. It goes to the PCP. Then, anyone else we need to tag in who is already known to the care of that patient could be added to this referral that goes out electronically. Now, we are all held responsible to each other. We have the greater level of accountability.
We met with the other stakeholders — PCPs, community paramedics — everyone agreed this was a great opportunity. We put together tracking tools and education programs. Then we went live.
The community paramedic goes into the home twice a week. Our care transitions nurse calls patients in between. We have a weekly huddle and we ask the PCP to see the patient post-discharge within 7 days. Our increased ask was to follow up with the patients just before 30 days after discharge. The community paramedic is who is responsible for closing out that discharge.
Healio: What are the results so far?
Magoon: It is a small number of patients, but we have been able to get our readmission rate down to 13.3%. We are excited. Additionally, the local social service agency is also connected to LeadingReach. That has been a huge benefit. If the team identifies a person who cannot afford medications, we can refer them to the agency. It is all built into the platform. We have been able to address patient needs in a way we have not been before. That has been a wonderful piece to be able to pull together in a new way.
Healio: You mentioned readmission rates falling and addressing patient needs. Any other lessons learned since implementing this program?
Magoon: For the patients readmitted, we found there was often no support in the home. When there is good support in place, and we support that home support, patients tend to do better. We recognize that is a challenge.
Another challenge is end-of-life care. We want to help the patient and family better recognize that is where they are and help them through. It’s one thing to complete your advanced directive counseling, but patients need emotional and spiritual support. We recognize that we need to add that into the program, as well as behavioral health support.
Gattis: What Dr. Magoon just illustrated is the definition of the team-based approach to health care. You cannot build on programs like this one unless there is a good foundation in place to make sure the patients get what they need. We can say we have gone from 23% to 13%. Now, how do we tackle the more challenging pieces? Some patients have no support network. Some patients cannot or will not take ownership of their health. Then there are those who do want help but do not have the resources. This program gives the PCP the opportunity to hold that network accountable. Our technology allows us to monitor and see what is going on. We can see who is having staffing issues. We can monitor what is going on across the network and identify gaps in personnel and other challenges.
Healio: Are there plans to expand on this program?
Magoon: We do plan to expand and take on additional diagnoses. In addition to HF, we would like to take on sepsis follow-up. That is our other big primary diagnosis that ends up with a readmission. We want to add a broader profile of patients and then look to continue to add additional community-based organizations, see if we can identify someone to help us with behavioral health support, as well as the additional pieces of the medical community at large that can benefit our patients. It’s all about right care, right time, right resources.
Gattis: This is exciting for us to empower these thought leaders and physician leaders in the communities we work in. We are big believers in value-based care. We want the PCPs to have the ability to be actively managing their patients’ health. If we can stop some of these problems at the PCP level and reduce specialist burden, we will have healthier communities. I love bringing our technology to the table and listening. Software never sleeps; we are always doing new things. We look at what the Dr. Magoons of the world see as the next-level challenges and we go and support efforts to make these communities thrive.
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