Cardiovascular disease is the leading cause of death in the United States.1 Heart failure (HF) is an extremely common cardiovascular disease affecting about six million Americans every year, a number that is estimated to increase to eight million by 2030, with over one million hospitalizations per year.(1,2) About 20% to 30% of these patients are readmitted within the first 30 to 90 days after the initial hospitalization.(3) Rates of HF readmission were seen to increase from 2010 to 2017.(4) The rise in HF readmission is concerning, not only from a patient safety perspective, but also financially. The average cost of a patient admitted for HF readmission in the United States is $15,618, with $30.7 billion spent in 2012.(5,6) Thus, HF readmission has become an increasing financial concern for hospitals.
Although HF has always been a concern, hospitals felt an additional impact from the COVID-19 pandemic. In addition to creating new concerns for hospitals, the pandemic also affected HF and its readmission rates. A great deal of research has been performed to analyze the reasoning behind the high readmission rates and to determine ways to reduce these rates. Research also has investigated the efficacy of these methods.
In this study, we describe the multidisciplinary method implemented by a single hospital during the COVID-19 pandemic to reduce the rate of HF readmissions.
Methods
The core focus of the HF navigator is to help navigate the care of the HF patient from admission to discharge and beyond. The HF navigator provides the patient and family members with the education and resources needed to successfully manage HF symptoms at home, with the goal of preventing the need for further hospitalization. The role of the HF navigator consists of four core functions:
Identify current hospitalized patients with new or newly diagnosed HF;
Provide individualized education focusing on diet and medication compliance;
Ensure each patient has the correct orders; and
Act as a liaison between the patient and the HF specialist.
Heart Failure Education
The navigator educates all hospitalized patients with new or newly diagnosed HF, providing patient-specific education and handouts. (Some of the key points emphasized are listed in the sidebar.)
Sidebar: Important Points to Discuss With Patients With Congestive Heart Failure
The congestive heart failure disease process
Signs and symptoms of congestive heart failure
When to call the cardiologist
Adhere to a low-sodium diet of 2000 mg per day
Restrict fluid intake to 2000 mL or 64 oz per day, unless told to drink less by a nephrologist
Monitor daily weight and call cardiologist with any weight gain of 3 or more pounds in one day or 5 pounds in one week
Monitor lower extremity edema
Monitor shortness of breath
Follow up with cardiologist within 1 week of discharge, as instructed
Importance of taking all medications
Specific medications used to treat congestive heart failure and potential common side effects
The navigator explains the basic HF disease process using simple layman’s terms, describing common signs and symptoms of HF and when to call the cardiologist. The navigator emphasizes ways the patient can manage HF symptoms at home, including monitoring daily weight, lower extremity edema, and shortness of breath; limiting sodium and fluid intake; and taking prescribed medications. Because medication compliance can be a common cause of readmission in this patient population, the navigator reviews each medication, stresses the importance of medication compliance, and discusses common side effects. Lastly, the navigator educates patients about the importance of recording and monitoring daily weights at home and contacting the cardiologist with any three-pound weight gain overnight, because increases in body weight are associated with hospitalization for HF and begin at least one week before admission.(7) The hospital also provides a complimentary scale to patients who do not have a scale at home. Patients are given a handout that summarizes the navigator’s teaching (Figure 1). During the follow-up discharge phone call made by the navigator within seven days of discharge, the patient is asked what their current weight was that morning. The HF navigator follows up with patients to help track and trend daily weights, forming a partnership of accountability with the patient.
Figure 1. Handout provided to patients when discussing congestive heart failure with patients.
Low-Sodium Diet Education
Dietary sodium restriction is the most commonly recommended self-care behavior for patients with HF and is endorsed by all HF guidelines.(8) Low-sodium diet education was identified at our institution as an immediate need for patients with HF. The navigator and clinical dietitian at the study site collaborated to create a HF-specific nutrition booklet written between a sixth- and eighth-grade reading level. The booklet explains healthy low-sodium food choices and the importance of reading labels. This specific tool is used when the HF navigator meets with the patient or the patient’s primary learner. If additional dietary education is required, the HF navigator sets up a dietician consult so that a clinical dietician can speak with the patient and provide supplementary information and resources. If the patient requires further dietary education after discharge, the HF navigator uses the site’s outpatient clinical dietician services to address the patient’s ongoing dietary questions and needs.
Infusion Center
One gap in the care continuum was identified during the implementation of the HF navigator process. Certain patients who do not need to be hospitalized but need intravenous diuresis had no location to receive this treatment other than the emergency department. An infusion center was created for those HF patients who need additional intravenous diuresis, but do not need to be hospitalized. The community hospital had an existing outpatient ambulatory location where non-oncology infusions (e.g., iron, blood transfusions) were performed. The team engaged with the leadership of the infusion center and developed a workflow to allow diuretic infusions to be performed. They created a process diagram, and workflows were designed to allow the patients to receive the diuretic infusions.
The patient calls the cardiologist when experiencing signs of fluid overload, and the cardiologist determines whether the patient needs diuresis at the infusion center. If so, the cardiologist completes the diuretic infusion order set, which includes the inclusion and exclusion criteria, laboratory orders, infusion orders, electrolyte replacement orders, and monitoring criteria. One area of future work will be to increase the availability of the infusion center for diuresis. Current efforts have targeted the cardiologists; future efforts will focus on primary care providers.
Heart Failure Follow-Up Appointments
Having close follow-up with either cardiology or the primary care provider after discharge has been shown to reduce readmissions.(9) The HF navigator emphasizes to patients the importance of following up with their cardiologist or heart failure specialist within five to seven days after discharge. Prior to discharge, in consultation with the patient, the navigator schedules the one-week follow-up appointment with the cardiologist or HF specialist and enters the appointment in the patient’s discharge instructions.
Home Health Care and Telehealth
If the navigator believes the patient requires additional monitoring after discharge, she works with the provider to obtain telehealth home healthcare services. Before discharge, if the patient is considered appropriate for telehealth, the patient is provided a monitor with a scale, blood pressure cuff, and pulse oximeter to record daily vital signs. The daily vital signs are transmitted to a registered nurse, who contacts the patient or the provider if the vital signs are abnormal. Typically, patients are on telehealth in the home for 60 days. Home healthcare staff also can provide additional reinforcement regarding medication and dietary compliance. The home healthcare liaison participates in the monthly HF meeting and provides feedback to the team on any patients who may have been readmitted or who have challenges in the home setting.
Follow-Up Phone Calls
The HF navigator contacts patients at home one week after discharge to reinforce inpatient education, including monitoring daily weight, lower extremity edema, and shortness of breath; limiting sodium and fluid intake; and taking prescribed medications. The navigator also encourages patients to call their cardiologist, HF specialist, or primary care provider, or the HF navigator with any questions or concerns. Feedback from post-discharge calls has always been positive, and patients can repeat back education provided.
Address Broader Health Concerns
The team worked to ensure that broader determinants of care were met. Patients were established with a primary care physician, if they did not have a preexisting relationship with one, and were educated on the importance of medication compliance to ensure they could live healthier lives outside hospitals. The team stressed the importance of follow-up with cardiologists and in other areas of health, such as treatment of obstructive sleep apnea.
Cardiac Rehab Referral
The heart failure navigator identifies appropriate patients who meet the criteria for cardiac rehabilitation and obtains an order from the physician. She then discusses cardiac rehabilitation with patients and explains the benefits of the program to improve overall heart function. She continues to promote and encourage the use of cardiac rehabilitation services with physicians and residents.
Discussion
This study found 235 readmissions for HF out of 1192 hospitalizations between 2018 and 2019, with a mortality of 28 deaths in 1237 hospitalizations. In the years 2020 and 2021, there were 156 readmissions from 1008 hospitalizations and a mortality rate of 17 deaths from 1058 hospitalizations. The methods previously described demonstrate a significant reduction (p = .0185) in HF readmissions after HF navigator implementation without a significant change in mortality (p = .2674) (Table 1). These findings show a significant decrease in HF readmission rate without a significant change in mortality, showing an overall reduction after implementation of the patient navigator.
Our results are novel. Yousufuddin et al.(10) demonstrated significantly reduced readmission rate, but also significantly elevated mortality rates during the COVID-19 era. Additionally, Babapoor-Farrokhran et al.(11) showed increased readmission rate and length of stay. Our study demonstrated a reduced readmission rate without a change in mortality, indicating the decrease in readmissions is from the implemented methods rather than from patient mortality.
Goldgrab et al.(12) hypothesize that heart failure readmissions are difficult to control and are thus inevitable due to the chronic nature of the disease. This was contrasted to conditions such as pneumonia, which is an acute syndrome compared with chronic syndromes. HF requires patients to make independent decisions on management at home regarding their symptoms.
Although HF is a chronic condition, the question remains regarding the driving factor of readmissions. Keeney et al’s.(13) review looked at frailty versus functionality as a predictor of readmission and they were unable to use either as a predictable factor for readmission. Sevilla-Cazes et al.(14) furthered this question by interviewing patients regarding their limitation of avoiding hospitals. The patients reported the driving factor was uncertainty surrounding recommendations, leading to inability to make decisions and a sense of hopelessness.(14) Education for patients can assist in patient decision making. Rice et al.(15) provided one-on-one education for patients, which resulted in improved quality of life and decreased readmission rate. Our method uses a multidisciplinary approach to patient education to empower patients with knowledge so they can feel confident making decisions independently.
Hamilton et al.(16) performed a review of systems shown to improve heart failure readmission rate: increased salt focus; increased exercise; in-home cooking; and access to providers over the phone. Our multidisciplinary approach aims to improve patient education in these areas, thus empowering patients with knowledge. The literature has shown that multidisciplinary approaches are most effective at reducing readmission rates, and thus we emphasize a multidisciplinary approach.(17-20)
One of the limitations of this study is that this is a retrospective study performed at a single institution. Retrospective data carries an inherent limitation. Also, because this was a single-center study, it is difficult to generalize and apply our intervention to other systems, although we believe it will have significant impacts in other facilities based upon our results. Additionally, there are differences between the total hospitalizations in the mortality and readmission calculations. This difference is the result of the tracking software used by the hospital. Two different programs are used to track the heart failure readmissions and the mortality rate. Despite these differences, transposing hospitalization values does not alter the significance of the results. The data represented are all-cause readmission, not limited to patients with a primary admission of heart failure and heart failure readmission.
Conclusion
This study demonstrates a high degree of value for patients, hospitals, and the U.S. healthcare system. Using the method we have described, patients can avoid hospital readmissions and live healthier lives at home. Reducing readmissions without worsening patient mortality previously was an elusive goal, but the study demonstrates that with sustained focus it is possible. The implications for hospital systems are significant. This study demonstrates that chronic conditions can be effectively managed through a multidisciplinary outpatient approach, reducing penalties faced by hospitals for readmission. Another benefit of decreasing readmission is that it frees up staff to care for additional patients at a time where many healthcare systems are operating with limited staff capacity.
According to CMS, U.S. healthcare expenditures totaled $4.3 billion—or 18.3% of gross domestic product—in 2021.(21) And 31% of those healthcare expenditures occurred in the hospital setting. Lesyuk et al.(22) demonstrate that between 1% and 2% of total U.S. healthcare expenditures are related to congestive HF, implying significant economic opportunity.
Our results continue to be sustained at the study site and are potentially replicable if resources can be devoted to the congestive heart failure population. The methodology was highly successful and has been replicated in patient populations with other chronic diseases, including chronic obstructive pulmonary disease. Additional patient populations with chronic illness may benefit from implementation of a navigator program. Implications for future practice should focus on the expansion of managing patients with chronic illness outside of the costly inpatient hospital setting. Future studies may expand upon this with the use of remote patient monitoring to identify changes in patient status sooner, further reducing readmissions and keeping patients happy and healthier at home.
References
Ruppar TM, Cooper PS, Mehr DR, Delgado JM, Dunbar-Jacob JM. Medication adherence interventions improve heart failure mortality and readmission rates: systemic review and meta-analysis of controlled trials. J Am Heart Assoc. 2016;5:e002606. https://doi.org/10.1161/JAHA.115.002606
Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141:e139-596. https://doi.org/10.1161/cir.0000000000000757
Palazzuoli A, Evangelista I, Ruocco G, et al. Early readmission for heart failure: an avoidable or ineluctable debacle? Int J Cardiol. 2019;277:186-195. https://doi.org/10.1016/j.ijcard.2018.09.039
Khan MS, Sreenivasan J, Lateef N, et al. Trends in 30- and 90-day readmission rates for heart failure. Circ Heart Fail. 2021;14:e008335. https://doi.org/10.1161/CIRCHEARTFAILURE.121.008335
Kwok CS, Abramov D, Parwani P, et al. Cost of inpatient heart failure care and 30-day readmissions in the United States. Int J Cardiol. 2021;329:115-122. https://doi.org/10.1016/j.ijcard.2020.12.020
Ziaeian B, Fonarow GC. The prevention of hospital readmissions in heart failure. Prog Cardiovasc Dis. 2016;58:379-385. https://doi.org/10.1016/j.pcad.2015.09.004
Chaudhry SI, Wang Y, Concato J, Gill TM, Krumholz HM. Patterns of weight change preceding hospitalization for heart failure. Circulation. 2007;116:1549-1554. https://doi.org/10.1161/CIRCULATIONAHA.107.690768
Riegel B, Moser DK, Powell M, Rector TS, Havranek EP. Nonpharmacologic care by heart failure experts. J Card Fail. 2006;12(2):149-153. https://doi.org/10.1016/j.cardfail.2005.10.004
Nair R, Lak H, Hasan S, Gunasekaran D, Babar A, Gopalakrishna KV. Reducing all-cause 30-day hospital readmissions for patients presenting with acute heart failure exacerbations: a quality improvement initiative. Cureus. 2020;12(3):e7420. https://doi.org/10.7759/cureus.7420
Yousufuddin M, Yamani MH, Kashani KB, et al. Characteristics, treatment patterns, and clinical outcomes after heart failure hospitalizations during the COVID-19 pandemic, March to October 2020. Mayo Clin Proc. 2023;98(1):1-32. https://doi.org/10.1016/j.mayocp.2022.09.005
Babapoor-Farrokhran S, Alzubi J, Port Z, Sooknanan N, Ammari Z, Al-Sarie M, Bozorgnia B. Impact of COVID-19 on heart failure hospitalizations. SN Comprehensive Clinical Medicine. 2021;3:2088-2092. https://doi.org/10.1007/s42399-021-01005-z
Goldgrab D, Balakumaran K, Kim MJ, Tabtabai SR. Updates in heart failure 30-day readmission prevention. Heart Fail Rev. 2019;24:177-187. https://doi.org/10.1007/s10741-018-9754-4
Keeney TJ, Jette DU, Cabral H, Jette AM. Frailty and function in heart failure: predictors of 30-day hospital readmission? J Geriatr Phys Ther. 2021;44(2):101-107. https://doi.org/10.1519/jpt.0000000000000243
Sevilla-Cazes J, Ahmad FS, Bowles KH, et al. Heart failure home management challenges and reasons for readmission: a qualitative study to understand the patient’s perspective. J Gen Intern Med. 2018;33:1700-1707. https://doi.org/10.1007/s11606-018-4542-3
Rice H, Say R, Betihavas V. The effect of nurse-led education on hospitalization, readmission, quality of life and cost in adults with heart failure. A systematic review. Patient Educ Couns. 2018;101:363-374. https://doi.org/10.1016/j.pec.2017.10.002
Hamilton B, Yadav C, Gomez D, et al. Heart failure readmission reductions during the COVID-19 pandemic. Nurs Manage. 2022;53(4):26-33. https://doi.org/10.1097/01.NUMA.0000824048.91690.74
Drozda JP Jr, Smith DA, Freiman PC, Pursley J, VanSlette JA, Smith TR. Heart failure readmission reduction. Am J Med Qual. 2017;32(2):134-140. https://doi.org/10.1177/1062860616637684
Feltner C, Jones CD, Cené CW, et al. Transitional care interventions to prevent readmissions for persons with heart failure a systemic review and meta-analysis. Ann Intern Med. 2014;160:774-784. https://doi.org/10.7326/M14-0083 .
Di Palo KE, Patel K, Assafin M, Piña IL. Implementation of a patient navigator program to reduce 30-day heart failure readmission rate. Prog Cardiovasc Dis. 2017;60:259-266. https://doi.org/10.1016/j.pcad.2017.07.004
Kratka AK, Britton KA, Thompson RW, Wasfy JH. National hospital initiatives to improve performance on heart failure readmission metrics. Cardiovasc Revasc Med. 2021;31:78-82. https://doi.org/10.1016/j.carrev.2020.12.015
Centers for Medicare & Medicaid Services. National Health Expenditure Fact Sheet. 2021. www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet . Accessed April 3, 2023.
Lesyuk W, Kriza C, Kolominsky-Rabas P. Cost-of-illness studies in heart failure: a systematic review 2004–2016. BMC Cardiovasc Dis. 2018;18:74. https://doi.org/10.1186/s12872-018-0815-3