30-Day Heart Failure Readmission, Research Paper Example

Introduction

Heart failure is one of the most troublesome health disorders for the modern US population; the numbers of people admitted and readmitted to hospitals with the heart failure diagnosis have given substantially within the past decade. While the estimated number of people diagnosed with heart failure in 2006 in the USA was about 4.8 million, the annual increase in the new heart failure cases occurs at a rate of 400,000 new patients, while the prospects for the near future indicate 550,000 of new cases (Jacobs, 2011). The present statistics shows how serious the problem of heart failure is for Americans in the contemporary period, especially taking into account the nation’s aging process, and the transition of baby boomers to the pension age.

However, not only the gravity of the disease and its adverse consequences for the human state of health trouble the healthcare establishments, experts, and policymakers nowadays. The 2011 Healthcare Business Market Research Hand book (2011) gave an estimate of 30-day hospital readmission for the Medicare patients with health failure; the results are too high, showing that 17.6% of patients discharged after a heart failure face readmission within the first month of discharge (Miller, 2011). These are the results indicated by the Medicare Payment Advisory Commission (MedPAC) – the prime responsibility of the commission is to track the Medicare expenditures and to detect the potentially avoidable ones for the sake of producing recommendations on the cost reduction. The financial impact of the detected readmissions is about $7,200 for each one, which constitutes millions of dollars annually for all readmitted patients. The irrational allocation of costs is evident, and the reason seen for the present inconsistency in healthcare is absence of healthcare continuity, and the inability of healthcare establishments to provide proper follow-up care for discharged patients.

The findings of Centers for Medicare and Medicaid Services (CMS) indicate a similar trend in the 30-day readmissions with the diagnosis of heart failure. The CMS statistics indicates that there are 19.5% of readmission total for the USA, while five states (Maryland, New Jersey, Louisiana, Illinois, and Mississippi) have the rates of readmissions 45% higher than the states showing the lowest readmission percentage (Miller, 2011). There is a clear need for research to identify the roots for high readmission rates and to delineate policies and reforms to ensure their reduction.  Specific attention should be paid to the fact that 76% of all readmissions in the USA are considered preventable and avoidable, which throws a shade on the currently applied and recognized discharge procedures in the US healthcare institutions.

One of the most feasible incentives for targeting the readmission rates in the USA is the huge negative financial impact this phenomenon entails for the commercial and federal healthcare providers. The Medicaid and Medicare losses only due to readmissions with heart failure constitute about $590 million annually (which occupies the first place in the readmission rating nationwide), while other top reasons for readmissions are also connected with cardiovascular diseases:

• chronic obstructive pulmonary disease (COPD; $345 million)
• acute myocardial infarction ($136 million)
• coronary artery bypass graft (CABG, $151 million)
• percutaneous transluminal coronary angioplasty (PTCA; $359 million) (Miller, 2011).

Intense research conducted nowadays on the subject of justifying the high rates of readmissions or identifying their preventable reasons indicates that there are a large number of patients discharged without proper instruction about managing their care at home after the hospital stay (65%), and the overwhelming majority does not receive the basic home care referral (81%), which is completely unacceptable in regard to the severity of heart failure and the long period of symptoms and comorbidities’ manifestation (Bisognano & Boutwell, 2009). Hence, the conclusion from the present data can suggest that in order to reduce the hospital readmission rates, healthcare institutions have to facilitate the patients’ transition from a hospital setting to the home environment.

The reason for inconsistency of health care provided in hospitals derives mainly from the extreme fragmentation of healthcare services provided; therefore, there are obvious challenges for the healthcare staff in working as a team (Bisognano & Boutwell, 2009). For this reason, the notion of hospital discharge has received a negative connotation among patients and healthcare experts. The implications standing behind the discharge notion are that patients are not provided with basic education, instruction, planning, and preparation before, during, and after the discharge (Bisognano & Boutwell, 2009). There is no proper information about medications, dietary provisions, weight control, lifestyle changes, etc., provided for patients who remain face to face with the consequences of their heart failure.

There is no doubt that the role of the nursing staff is the key to the reduction of hospital readmission rates. Advanced practice nurses (which is a very diverse notion encompassing several types of registered and licensed nurses entitled to provide healthcare services previously assigned to medical doctors) provide the in-patient and out-patient care for the patients, and may be regarded as the closest personnel members knowledgeable about the patients’ state of health and recovery dynamics. Their involvement in the follow-up care is thus the main indicator of discharge effectiveness. Miller (2011) claimed that the main path to improvement of the situation with readmissions is to employ advance practice nurses as coaches for patients during their stay in the hospital and after their discharge.

The key function of APNs as coaches would be to educate patients about the basics of self-care and self-management, the changes in the lifestyle implied by heart failure, the diet they have to keep to, the regime favorable for recovery, the symptoms of co-morbidity, weight control and medication administration fundamentals, etc. Another option proposed by Miller (2011) is to create virtual terminals in the hospital settings that would provide patients with computerized information provision and consultation system. The feedback from customers can be acquired through the user-friendly computer touch screen, and all data needed for patients during their hospital stay and after the discharge would be provided through voice or textual messages.

Another alternative is offered by Bisognano & Boutwell (2009) who regard the high rates of readmissions as the explicit defect in the hospital’s planning and care processes, or in the ambulatory system of the healthcare institution, or the community in which heart failure reoccurs for unknown reasons. In connection with this, most commercial payers have initiated the systematic reporting of hospital- and physician-specific 30-day readmission rates to respond appropriately as for the readmission rate reduction. Hence, the authors supposed that in order to change the situation, such factors should be taken into account in the hospital settings:

• error-free, high-quality in-patient care systems
• efficient medication reconciliation
• patient education during hospital stay
• discharge planning focused on the patients’ needs
• post-discharge support for patients and caregivers
• post-discharge follow-up care with the intensity of referral appropriate for the individual patient needs
• ensuring a clear idea of the clinical prognosis for the patient by him/her and his/her caregivers
• proactive end-of-life care planning effort (Bisognano & Boutwell, 2009, p. 6).

As the present overview of the problem indicates, there is much to be done for the sake of readmission rates’ reduction. However, the main emphasis has to be made on APNs, since they are the prime stakeholders who ensure following the success factors delineated above. The follow-up care and in-hospital education appear the most significant predictors of 30-day readmission for patients with a heart failure. However, there is little unified, explicit evidence about the ways to engage APNs in the readmission rate reduction. Therefore, the research question for the present critical review paper is as follows:

How can Advanced Practice Nurses contribute to the reduction of 30-day readmission rates for patients with heart failure?

The present research question appears significant for the evidence-based research on hospital readmission rates, since the APNs are acquiring a more significant portion of responsibilities nowadays with the transformation of healthcare. Licensed nurses expand the scope of their influence in the healthcare settings, and they represent the personnel most knowledgeable and closest to the patients. APNs are responsible for medication plans, monitoring the dynamics of the patient’s recovery, educating patients about their medications and therapies, and providing them with all necessary information upon discharge. Though these are the functions of nurses that help patients tremendously, there is a clear need for more follow-up care, and APNs can play the key function in ensuring patient follow-up during the first weeks and months upon the discharge.

Literature Search Process and Inclusion Criteria

Since the present literature review initially intended to gather and analyze empirical research data derived from studies conducted recently, the main emphasis in the process of literature search was made on empirical studies in the field of heart failure readmission rate investigation and the assessment of the role of APNs in the follow-up care, patient education, and discharge planning for the sake of readmission rate reduction. The databases utilized for the present research were the EBSCI Host Database, the MedLine database, and the PubMed database. All of them offered much information on the issue of heart failure readmission and the role of APNs in the reduction of readmission rates.

However, the majority of the articles had to be excluded from the list of resources used in the present study because they did not satisfy the inclusion criteria. The inclusion criteria were chosen as follows:

• research dedicated to heart failure readmission rates
• research dealing with the role of APNs in the heart failure patients’ follow-up care
• research containing empirical evidence
• research published in 2005-2010 and later
• articles written in English

Two articles were chosen disregarding the present inclusion criteria; one article is the one of Naylor et al. (2004) dedicated to the transitional care model. Naylor was the pioneer in recognizing the key role of APNs in the provision of adequate transition for heart failure patients from hospital to home; hence, the researcher was the first to generate a transitional care model based on the comprehensive participation of the APN in the follow-up care for the HF patients. All subsequent research in the field of aligning APNs and follow-up care for the sake of readmission rate reduction is based on the works of Naylor; hence, it was due to the exceptional importance of this article for the present paper that it was included ignoring the publication limits.

Another article that neglected the empirical evidence criterion was the article of Delgado-Passler and McCaffrey (2006). It was chosen for review in the present paper due to the key question it raised – whether the APNs or RNs can provide HF patients with effective follow-up care after the discharge from the hospital settings. The authors assessed practical evidence laid out by other researchers to conclude that only APNs are capable of providing the comprehensive framework of follow-up care for the HF patients. These conclusions possess key importance for the present paper as it proves the necessity of APNs’ involvement in the follow-up care for heart failure patients for the improved outcomes thereof.

Discussion

As it comes from the present critical review, the majority of studies, both qualitative and quantitative, provide a unanimous positive assessment of the role of APNs in the follow-up transition care for the heart failure patients. There is sound evidence for this assumption, since all cases with APN intervention in the hospital settings with the further follow-up calls and visits have caused a substantial increase in the quality of life of heart failure patients, their satisfaction, and the reduction of co-morbid symptoms’ severity. APNs are recognized nowadays as the main driving force for the implementation of readmission rate reduction in case of heart failure; the roots to this conclusion can be found in the increase of advanced practice nurses’ responsibilities in the healthcare settings. As Delgado-Passler and McCaffrey (2006) noted, APNs have the unique potential for follow-up care since they can assign and reassign medications, adapt dosage of medications to the dynamic state of the patient’s health, and they possess much deeper knowledge about the nature of heart failure and pathologies connected with it.

There are many projects to assist the introduction of transitional care by APNs for the heart failure patients, as a considerable body of research indicates the exclusive effectiveness of their involvement in follow-up care. For example, Fullerton, Stauffer, Stafford, and Ballard (2010), Jacobs (2011), and Schwartz, Mion, Hudock, amnd Litman (2008) assumed the effectiveness of APN intervention in the follow-up hospital care as compared to the absence of intervention and transition programs. The study of McCauley, Bixby, and Naylor (2006) conducted a bit earlier also suggests that APNs play a decisive role both in the readmission rate reduction, and in the cost-saving procedures for the healthcare institutions. The study of Jacobs (2011) is supported by earlier findings of Brandon (2008) who analyzed a great body of theoretical and practical evidence for the involvement of APNs in the process of follow-up care and transition for heart failure students, and found support for the usefulness of telephone interventions by APNs. In addition, Brandon assessed much evidence against the RN involvement in follow-up care; the researcher claimed that the studies of Whellan et al. (2002), Laramee et al. (2003), and DeBusk et al. (2004) all suggested the comparative advantage of APNs in the follow-up care due to deeper knowledge and more expertise in clinical states and symptoms related to heart failure (as cited in Brandon, 2008).

Obviously, it is necessary to take a close look at the concept of the transitional care model introduced by Naylor in 2004; the researcher recognized the fact that discharge, as it was before the invention of the transition concept, was the release of the patient to nowhere, and there was no link between his or her stay in the hospital and at home. There was no proper care about communicating the precautions to patients who have just suffered a heart failure, and no education about medications, their dosage, consequences of improper administration, and neglect to co-morbid symptoms and diet was provided. However, research suggested that older people struggling with the heart failure and its consequences were a very vulnerable group of patients during their transition to home settings (Naylor et al., 2004).

The present findings justify the transitional care approach to heart failure patients generated by Naylor (2004) and colleagues. The researcher indicated that the notion of transitional care is applicable to the range of time-limited services and environments designed to ensure the continuity of follow-up care, and to prevent the negative outcomes of challenging heath states among the high-risk patients (Naylor & Ware, 2009). Therefore, one can see that the true reasons for the emergence of a transitional care model are the high rates of errors in the healthcare provision, unmet needs of patients in acute states, and the poor level of patient satisfaction with healthcare.

Naylor and Ware (2009) also mentioned the high level of preventable readmissions as the core incentive for the transitional care application; finally, the tremendous human and cost burden is also regarded as the drive for generating and implementing the transitional care for heart failure patients; indeed, both patients suffering from serious health disorders and the state authorities will be relieved in case readmissions will occur more rarely. The quality of life for patients with heart failure can be much higher, in case it is properly organized, coordinated, and followed at home with properly educated caregivers and family members; the state will suffer fewer financial losses, while elderly patients will live in more social supportive environments, i.e., at home. The positive outcomes of transitional care implementation are obvious, and much additional effort on its implementation is needed as the prime way to achieve readmission rate reduction.

Schwartz, Mion, Hudock, and Litman (2008) introduced some additional dimensions in the research regarding follow-up care for heart failure patients; they attempted to explain the level of depression, quality of life, and severity of accompanying symptoms by the APNs’ intervention. One should assume that the failure of the Cardiocom EHM system occurred mainly due to the lack of accessibility of education and training regarding modern technological achievements for heart failure patients who are 65 and older, and rarely grasp the intricate mechanisms at work (Schwartz, Mion, Hudock, & Litman, 2008). Though their prime aim was to assess the telemonitoring system that proved to be of no significant use in the follow-up care, the quality of life with transition care by APNs was recognized and proven by the study findings.

There is not only theoretical but also practical evidence for the support of the necessity to involve APNs in the post-discharge transitional care; several follow-up programs employing APNs in the follow-up visits, calls, and telemonitoring have appeared a substantial success, which may be seen both from the patient and financial analysis. Some examples of successful implementation of APN effort in the follow-up care include the Project Re-Engineered Discharge (RED) program implemented at the Boston University School of Medicine, the Care Transitions Intervention (CTI) model applied in the University of Colorado in Denver (its supervisor and generator is Prof. Eric Coleman) (Miller, 2011). In contrast to the results of Schwartz, Mion, Hudock, and Litman (2008), the Fuqua Heart Center at Piedmont Hospital (Atlanta) has been highly successful in the implementation of a telehealth program to track the heart failure patients’ health status. The result was a dramatic increase in the hospital readmission rates – about 75% of projected readmissions have been prevented (Miller, 2011).

However, the follow-up care is still regarded as the best indicator of the successful efforts in the reduction of hospital readmission rates for heart failure patients. Thus, the Baylor University Medical Center has the lowest number of readmissions across the whole USA (Miller, 2011). The present achievement is attributed to the effective organization of follow-up care by the APNs employed in the inpatient and outpatient programs. These statistical data suggest that there is nothing better than the qualified care, support, and information assistance of an APN. Therefore, additional efforts should be made to disseminate the information about the benefits of transitional care, and to enhance engagement into transition care initiative creation throughout the country.

There is a realistic possibility to implement transitional care with APN involvement in the modern healthcare settings; Hines, Yum and Randall (2010) have proposed their three-stage model for the implementation of follow-up reform. The first stage is the reform and payment changes that involves increasing transparency in payment, introduction of bundled payments, and changing care delivery models. The second phase is the generation of strategies for readmission rate reduction; this phase includes the considerations about proper transitions home, the generation of a multidisciplinary follow-up, the establishment of home health programs, the introduction of the transitional care model, usage of telemonitoring devices, etc. (Hines, Yu, & Randall, 2010). Finally, the third stage includes the very process of reform execution; it presupposes the generation of program self-assessment, the identification of strategies and opportunities, and the creation of a realistic, feasible business plan. The essential component of the final stage is to ensure continuous support for all reform stakeholders (Hines, Yu, & Randall, 2010).

However, no matter how feasible and realistic the opportunities for the transitional care performed by APNs seem, there is a set of challenges on the way to improvement. Naylor and Ware (2009) estimated some of the potential barriers for the establishment of the transitional care model as a universally accepted pattern for the follow-up care arrangement. The researchers claimed that the organization of the current system of care, as well as the very culture of care, cannot allow the transitional care to become a widespread model. The reason for this is that healthcare is not patient-centered, but customer-centered, due to the extreme fragmentation of the healthcare system in the US, and the involvement of multiple payers, healthcare providers, etc. Therefore, the healthcare itself is highly fragmented as well, and it is hard for the patient to get the unified help of a single healthcare team in a single healthcare setting (Naylor & Ware, 2009).

In addition, the researchers emphasized the fact that lack of quality and financial incentives are the main reasons for the current neglect to the advantages of the transition care model (Naylor & Ware, 2009). Indeed, their claims seem reasonable, since even under the serious pressure for cost reduction and readmission handling, the majority of hospitals are not ready to risk and allocate additional funds for the sake of launching follow-up care. The empirical research findings state that the transitional care will be profitable for hospitals in any case, even if readmissions will not be reimbursed by federal and commercial healthcare providers.

The cost of a transition care program is also significant; for example, the net costs of the Baylor Healthcare System implemented in the Baylor University Medical Center (the most successful institution in the USA in terms of readmission rate reduction) are estimated at the rate of $76,326, which is rather expensive. The costs include APN salary, operating costs, and home visit reimbursements. However, in case the sum is compared to the $590 million of financial losses for the Medicare and Medicaid programs, one can make a positive choice for the transitional care, as in any case it turns out more effective, the positive outcomes are retained in the long term, and the cost savings are much more significant in comparison with readmission reimbursements.

The role of transitional care is evident in the provision of lower readmission rates, which would presuppose higher levels of patient care quality. The role of APNs is also essential in the transitional care, since the totality of evidence in the empirical and theoretical research available up to date emphasizes the necessity to involve APNs and not RNs in the follow-up care. Surely, it is obvious that even the comprehensive, logically designed, and thoughtfully implemented follow-up care program will fail in case inpatient care is improperly organized; hence, it is necessary for the APN to start the inpatient care from proper education of the patient and his/her caregivers (i.e., family members) about the essential components of self-management and self-care upon the discharge from hospital. Proper information about medications, effective and continuous education, explanation of significance of the sodium-free diet and weight control – all factors are significant in the provision of the successful and smooth discharge.

There is always a way for improvement and perfection of the follow-up and inpatient care; hence, APNs have to realize their central role in the reduction of readmission rates. There is an urgent necessity to look for a proper combination of follow-up and inpatient care methods for the sake of finding the proper balance; thus, for example, the Ideal Transition Home Model proposed by the IHI-Robert Wood Johnson Foundation (RWJF) Transforming Care at the Bedside (TCAB) dictates the need to include the caregivers and community care providers in the assessment, discharge planning, and need prediction from the very start of hospital admission (Bisognano & Boutwell, 2009). Hence, it is possible to consider the community care as an additional contributor to the successful outcomes of follow-up care, and to continue the development of positive models of home transition and living with the heart failure.

References

Bisognano, M., & Boutwell, A. (2009). Improving transitions to reduce readmissions. Frontiers of Health Services Management, 25(3), pp. 3-10.

Brandon, A. F. (2008). The effects of an advanced practice nurse-led telephone-based intervention on hospital admissions, quality of life, and self-care behaviors of heart failure patients. A Thesis Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Master of Science. Retrieved from http://etd.auburn.edu/etd/bitstream/handle/10415/1226/Brandon_Amy_11.pdf?sequence=1

Delgado-Passler, P., & McCaffrey, R. (2006). The influences of postdischarge management by nurse practitioners on hospital readmission of heart failure. Journal of the American Academy off Nurse Practitioners, 18, pp. 154-160.

Fullerton, C., Stauffer, B., Stafford, P., & Ballard, D. J. (2010). Transitional care program to improve heart failure outcomes. Baylor Health Care System. Retrieved from http://www.isqua.org/Uploads/Conference/Abstracts/D_BALLARD_%5BCompatibility_Mode%5Dwedam.pdf

Jacobs, B. (2011). Reducing heart failure hospital readmissions from skilled nursing facilities. Professional Case Management, 16(1), pp. 18-24.

Hines, P. A., Yu, K., & Randall, M. (2010). Preventing heart failure readmissions: is your organization prepared? Nursing Economics, 28(2), pp. 74-85.

McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9(5), pp. 302-308.

Miller, R. K. (2011). The 2011 healthcare business market research handbook. (15^th ed.). Loganville, GA: Richard K Miller & Associates.

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. Journal of American Geriatric Society, 52(5), pp. 675-684.

Naylor, M. D., & Ware, M. S. (2009). The transitional care model: translating research into practice. University of Pennsylvania, School of Nursing. Retrieved from http://www.queri.research.va.gov/chf/docs/HF_Program_Naylor.ppt

Schwartz, K. A., Mion, L. C., Hudock, D., & Litman, G. (2008). Telemonitoring of heart failure patients and their caregivers: a pilot randomized controlled trial. Progress in Cardiovascular Nursing (Winter 2008), pp. 18-25.