RelateCare and the Special Case of Heart Patients

Heart related issues are the leading cause of hospitalization among adults over 65 in the United States. Every year, over one million patients are hospitalized with a primary diagnosis of heart failure, which accounts for around $17 billion in Medicare expenditure. This number is also set to increase by up to 40% in the next 15 years.

Readmission rates are a particular problem when it comes to heart failure, with over 50% of patients readmitted to hospital within six months of discharge. (5-7) Nationally, nearly one in five patients hospitalized with heart attack and one in four patients hospitalized with heart failure are readmitted within 30 days of discharge, often for conditions seemingly unrelated to the original diagnosis, according to the American College of Cardiology. Readmissions can be related to issues like stresses within the hospital, fragility on discharge, lack of understanding of discharge instructions and inability to carry out discharge instructions.

It is by now well known that a reduction in readmission rates might simultaneously reduce costs and improve the quality of care. Many health systems have increasingly viewed readmission rates as a focus of interventions that can move care closer to a value-based model. This particularly so since the Patient Protection and Affordable Care Act established financial penalties for hospitals with high readmission rates (although who knows what is going to happen under the new administration!)

RelateCare has been focused on developing programs to reduce readmission rates since 2011. Working with one of the world’s leading cardiac institutions we have designed robust, specialized cardiac-focused Post-Discharge Follow-Up Program that has been rolled out in several leading healthcare organizations across the U.S.

When it comes to reducing readmissions and improving continuity of care for heart patients, program design must be particularly robust, and communication must be frequent and engaging.

Patients who have undergone heart procedures are inherently complex and susceptible to relapse. Therefore, it is essential that a Post-Discharge Program keep these issues in mind.

For RelateCare, this means the following:

  • Complex cases: Firstly, the calls are made by RelateCare Registered Nurse as the issues faced by cardiac patients are more complex and require the skills and expertise of a fully qualified nurse rather than a medical practitioner.
  • Frequent communication: More frequent calls are required to ensure a smooth transition from hospital to home and ensure higher levels of patient engagement.
  • Care coordination: Greater communication between RelateCare and the care coordination team, nurse practitioner, and physician responsible for the patient. It is essential that proper care coordination connects the patient, the care coordination team, and the discharge support.

In 2014, RelateCare, on behalf of the Heart and Vascular Institute of a leading health institute, contacted 5,632 patients with 8% (490 patients) being readmitted, compared to 3,724 of patients who could not be contacted, with a readmission rate of 13% (508). It is clear that those contacted had a lower readmission rate than those not contacted.

In 2015 the re-admission rate for contacted patients (47,702) vs unable to contact (24,743) was 10.4% (4,770) vs. 11.3% (2,765). Again, maintaining a reduction in readmissions for those contacted compared to those not contacted.

By addressing these patient issues early into their return to home or home health the Post Discharge Call-Back Program can catch any red flags that may appear and save on costly readmissions.

  1. Krumholz HM, Merrill AR, Schone EM, Schreiner GC, Chen J, Bradley EH, Wang Y, Wang Y, LinZ, Straube BM, Rapp MT, Normand SL, Drye EE. Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission. Circ Cardiovasc Qual Outcomes. 2009;2:407–413.
  1. Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and why? Implications for efforts to improve care using financial incentives. Circ Cardiovasc Qual Outcomes. 2011;4:53–59.
  1. Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS. Lifetime analysis of hospitalizations and survival of patients newly-admitted with heart failure. Circ Heart Fail. May 2 ,2012. doi 10.1161/CIRCHEARTFAILURE.111.964791http://circheartfailure.ahajournals.org.Accessed April 19, 2012.

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