HFSA ePoster Library

Introduction: Heart Failure is an “outpatient” illness, which if effectively managed will reduce hospitalizations, cost of care, and improve quality of life. As of March 2020, there were 3,799 patients at the Orlando Veterans Affairs Healthcare System (OVAHCS) diagnosed with heart failure (HF). In 2019, facility HF admission rates remained a challenge as the number of yearly admissions, per unique, was 2.09. The HF Program developed an innovative, multidisciplinary team with targeted roles enhancing comprehensive services to accomplish our goal of reducing admissions and readmissions among HF patients.
Goals: Reduce HF admission and readmissions, positively impacting care outcomes among high-risk HF patients at OVAHCS through intense oversight, prompt intervention, and enhanced self-management skills facilitated by the efforts of a multi-disciplinary team.
Methods: A Transitions of Care Team was operationalized to ensure proper discharge diagnosis, adequate discharge medication supply, follow-up appointment prior to discharge, timely medication up-titration, and close post-discharge symptom management for 31-days. Weekly calls to patients with 2+ HF admissions in recent 12 months, known as the frequently admitted, provided opportunities for intense oversight, prompt intervention, and enhanced self-management support. A new High Risk Shared Medical Appointment was developed for these frequently admitted patients. The HF Program expanded staffing to include a wider range of disciplines targeting complex patient needs. Weekly team huddles were initiated to provide a multidisciplinary collaborative approach to crisis intervention and improved care management efforts/outcomes.
Results: From March through December 2020, facility HF admissions were reduced by 14% and readmissions were reduced by 4%. The number of facility HF admissions, per unique, was reduced from 2.09 to 1.15. The total number of facility patients with a recent HF admission was reduced from 247 to 217. The number of high risk patients with 2+ HF related admissions was reduced from 86 (March 2020) to 40 (December 2020) which is a 54% reduction. One year after effort implementation (April 2021), this was further reduced to 32 (63% reduction).
Conclusion: Through the expansion of the HF Program at the OVAHCS, HF admissions and readmissions were reduced. Adding new staff provided our team with resources to incorporate a proactive care approach for admission and readmission prevention. Through increased multi-disciplinary team interaction, prompt interventions and intense management of these complex patients with multiple comorbidities, access was improved to facilitate timely medical oversight. This improved care outcomes and opportunities for enhanced self-management skills through education, contributing to a better quality of life among our high-risk heart failure population.