“See You in Seven”What’s Happening in Cardiac

Rehab

Heather Shuster, MSManager, Population Health & Wellness

Genesis HealthCare System, Zanesville, OhioLean Six Sigma – Green Belt

Hospital to Home (H2H)The H2H national quality improvement

initiative is an effort to reduce cardiovascular-related hospital

readmissions and improve the transition from inpatient to outpatient status for

individuals hospitalized with cardiovascular disease. 

The H2H initiative is co-led by the American College of Cardiology (ACC) and the Institute for Healthcare

Improvement (IHI).

Hospital to Home (H2H)

H2H Goal:

To reduce all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction

by 20% by 2012.

Hospital to Home (H2H)

Why choose H2H?Nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, with heart failure listed as the common reason for readmission.

In 2004 alone, the total cost of these readmissions was $17.4 billion.

CMS reimbursement dependent on readmission rates

Hospital to Home (H2H)

“Right now hospitals, are not penalized if there are constant readmission rates from patients that have gone through

the hospital.”

Hospital to Home (H2H)H2H FocusH2H will focus on three main domains that provide opportunities for improvement:1.Medication Management Post-Discharge: Is the patient familiar and competent with their medications and do they have access to them?2.Early Follow-Up: Does the patient have a follow-up visit scheduled within a week of discharge and are they able to get there?3.Symptom Management: Does the patient fully comprehend the signs and symptoms that require medical attention and who to contact if they occur?

H2H: “See You In Seven”

Hospital to Home (H2H) have gathered expertise and experience around the “See You in Seven” (SY7) program, proven to reduce unnecessary

hospital readmissions and improve transitions of care for patients with CHF, AMI and PTCA/PCI.

The goal of SY7 is for all patients discharged with these diagnoses to start cardiac rehab or be seen at follow-up clinic within 7 days

of discharge.

H2H: “See You In Seven”Implementing a successful program:

1. Find your Champions (RNs, Drs., Managers etc.)

2. Develop inpatient process/staffing matrix for educating patients (Navigators, Nurse Educators)

3. Create learning/teaching tools

4. Develop process for scheduling and referring to follow-up clinic or Cardiac Rehab programs

H2H: “See You In Seven”1. Find your champions (RNs, Drs., Managers etc.)

- Create a committee of RNs, Drs., Managers etc. to work on developing, implementing and supporting the project.

- Buy-in from the nursing staff as well as managerial/physicians is imperative to making this

program successful.2. Develop an inpatient process/staffing matrix for educating

patients (e.g. Navigators, Nurse Educators)- Less teaching for admission and discharge nurses- Navigators or Nurse Educators provide "survival skill"

teachings to patients while in hospital- Set up appointment with clinic or cardiac rehab- Ensure patient compliance with follow-up appointment in clinic and/or cardiac rehab

H2H: “See You In Seven”3. Create teaching pathways/outline to ensure standardized

teaching methods and information are provided to every patient

- Create patient take-home folder with educational resources/materials- Quality teaching and learning time is established with

patient - Increased understanding of the materials and compliance

post- discharge4. Develop process for scheduling and referring to follow-up

clinic or cardiac rehab programs- Create standardized process for scheduling and referring

to outpatient services- Discuss, resolve and document any barriers to keeping

appointments- Patient provided with appointment reminder (e.g. Appt

card) to increase compliance- Follow-up clinic or cardiac rehab program establishes appointment slots for SY7 patients

H2H: “See You In Seven”Success Measures and Strategies

The hospital discharge process is successful if:

HF, AMI and PCI patients are identified prior to discharge

Clinic or cardiac rehab appointment within 7 days is scheduled and documented in the medical record

Patient is provided with documentation of the scheduled appointment (e.g. appointment card).

– Date, time, location, provider contact information.

Possible barriers to keeping appointment are identified in advance, addressed, and documented in the medical record

H2H: “See You In Seven”The follow-up clinic or cardiac rehab appointment is successful if:

Patient arrives at appointment within 7 days of discharge from hospitalDischarge summary (including summary of hospitalization, updated medication list) available to follow-up provider.Patient brings his/her medications or a medication list to appointmentReason for referral available to cardiac rehab and patient brings referral or provider prescription.

H2H:“See You In Seven”Implementation in the Cardiac Rehab Setting

Example process for transitioning patient from inpatient to outpatient:1.Navigator calls to schedule appointment with CR for patient within 7 days of discharge2.CR staff opens appointment time and schedules SY7 patient3.After patient is discharged, CR staff will contact patient to check up and remind patient to bring medications to appointment4.CR staff calls patient to remind them of appt (1 day prior)5.Patient arrives at CR at appointment time with medications6.Patient is oriented to the program and exercise equipment.7.Patient is placed on a restricted exercise prescription for the first week to allow for ample healing time and then will be transitioned for normal progression.

H2H:“See You In Seven” Outcomes

This is a new initiative for H2H due to the pending CMS reimbursements.

H2H Outcomes are still being assessed.

Supporting Research:AHA -Circulation (Reuters Health) – December 28, 2012

“Scheduling heart patients’ first cardiac rehabilitation session within 10 days of hospital discharge gets more of them to show up…”

“Researchers found the earlier scheduling led to 18% increase in attendance at the first orientation appointment compared to appointments scheduled a month or more after discharge”

Case Study: 148 randomized heart patients from Henry Ford Hospital in Detroit– 74 patients received appointments on average 8.4 days after discharge

• 77% attended orientation appointment (n=57)– 74 patients received appointment on average 42 days after discharge

• 59% attended orientation appointment (n=44)

• Dr. Quinn Pack, study lead author stated – – “I think what actually happens is people go home and they’re scared to exercise and

(they) go back to their dietary habits…and you are not able to capitalize on that habit change initiative.”

• Dr. Frank Richeson, Director of cardiac rehabilitation at the University of Rochester Medical Center in New York stated –

– “I was surprised that we didn’t know that already. Recruitment early when the iron is hot makes a lot of sense intuitively.”

Genesis Heart & Vascular Rehab2011 Lean Six Sigma Project – Increase units charged

Goal - Increase the percentage of average YTD charged units in Cardiac Rehab from –3% in August to 0% by December 31, 2011 as compared to 2010 charged units•Developed new scripting for scheduling eligible patients•Revised all handout materials to increase compliance•Charging for three 30 minute education classes that were previously not charged for (CPT 93797)•Started H2H “See You in Seven” Program •Wellness Coaching Sessions (3 units) for eligible clients•Working with IT to utilize EPIC for eligible patient lists and automatic order sets

Genesis: “See You In Seven”

Started in August 2011 Champions:

– Nurse Navigators (2012)– Heart & Vascular Diagnostics (Phase I)– HVR Medical Director– Administration– Lean Six Sigma

Genesis: “See You In Seven”Example of SY7 Referral to HVR

1. Patient identified by AMI/PCI/HF Navigators

2. Patient educated on benefits3. Navigator calls HVR program to

schedule4. Appointment scheduled within 7 days

of discharge and documented in medical record. (Automatic order on all cardiac patients in EPIC)

5. Educator provides patient with appointment card

6. HVR program contacts patient to complete paperwork following discharge

7. HVR program calls patient 1 day prior to appointment as a reminder

** Navigators would be following-up with patient as well to ensure compliance.

Genesis: “See You In Seven” Implementation Outcomes

60 pts. 66 pts. 73 pts. 97 pts.

Genesis: “See You In Seven”

Genesis: “See You In Seven”

Sept – $2,666Oct – $4,136Nov – $11, 042Dec - $26, 086

Genesis HVR Trends - Monthly Charged Units

Phase I Educators – consistent staff Navigators Hired

Genesis: “See You In Seven”

Avg. Sessions

= 35!

Avg. Sessions

= 35!Avg.

Sessions = 30

Avg. Sessions

= 30

Genesis: “See You In Seven”

Genesis: See You In SevenOutcomes

Average METs increase = 34%

100% had follow-up exercise plan documented

Average change in waist measurement = 1 inch

SY7 clients with weight loss goals lost on average 2 lbs. – One client lost 17 lbs.

Financial Impact (Jan-June 2013)

Total HVR Program profit = $37,026.80

The NEW Genesis HVR Gym

From the mouth one of our cardiologist to the wall of the

gym…

Genesis Heart Failure Exercise ProgramClients learn how to be more physically active and feel better

with exercise while successfully learning to improve their quality of life with heart failure.

This self-pay program includes:Exercise and education sessionsIntermittent EKG monitoringWeight monitoring

The goals of the program include:Improve quality of lifeDecrease risks associated with HFDecrease additional hospital staysLearn sustainable lifestyle changes

Clients learn how to be more physically active and feel better with exercise while successfully learning to improve their quality of life with peripheral artery

disease.

The goals of the program include:•Relieve symptoms of P.A.D.•Improve walking capacity•Decrease risks associated with P.A.D.•Improve quality of life

This self-pay program includes:•Exercise and education•Treadmill walking and strength training•One on one health assessment

“GOING THE DISTANCE WITH P.A.D.”

Clients who are at risk for chronic diseases such as diabetes, coronary artery disease,

stroke etc. can begin the journey to life long lifestyle changes.

Goals of the program:•Reduce risk factors•Education•Lifestyle modification•Improved quality of life

“Get a GRIP on your lifestyle” (GRIP)

Goals of the program:– Regulate blood glucose– Improved understanding of

diabetes self-management– Improved endurance and muscle

strength– Decreased cardiovascular risk– Improved quality of life

Diabetes Exercise ProgramLearn how to be active and feel

better with exercise while successfully controlling your blood sugars to get the most

out of your workout

Additional Resources: http://h2hquality.org

Heather Shuster, MSManager, Population Health & Wellness

Genesis HealthCare SystemZanesville, Ohio 43701

hshuster@genesishcs.org(740) 454-4086