By Martha HostetterIssue: More than 5 million Americans are living with heart failure (HF), a life-threatening condition that impairs the heart's ability to pump enough blood to meet the body's oxygen needs. It is most common among the elderly. While this chronic condition can be managed with appropriate medication and lifestyle changes, many patients experience acute exacerbations that result in trips to the emergency room. HF is one of the most common reasons people are admitted to a hospital—and the most common reason for readmission. Between 29 to 47 percent of elderly HF patients are readmitted for their condition within three to six months of an initial hospitalization. 
Programs such as Duke University's Heart Failure Program and the Transitional Care model created by Mary Naylor, R.N., at the University of Pennsylvania have shown that effective management of the condition could avoid many hospitalizations.
Catholic Healthcare Partners created a program—called Heart Failure Guidelines Applied in Practice (HF GAP) —to improve care for heart failure patients within its system by promoting the consistent use of evidence-based guidelines. This initiative grew out of an American Heart Association scientific statement published in 2000 that advocated the use of team care for heart failure management. (There is no formal relationship between Catholic Healthcare Partners' HF GAP program and other Guidelines Applied in Practice programs, such as one launched by the American College of Cardiology.)
Organization and Leadership: Catholic Healthcare Partners (CHP), which operates nine regional health care networks, is one of the largest nonprofit health systems in the U.S. Based in Cincinnati, Ohio, it operates hospitals, long-term care facilities, home health agencies, hospice programs, wellness centers, and other health care facilities in Indiana, Kentucky, Ohio, Pennsylvania, and Tennessee.
Donald Casey, M.D., currently the vice president for quality and chief medical officer at Atlantic Health, was the principal investigator of the HF GAP initiative while serving as chief medical officer at Catholic Healthcare Partners, from 2002 to 2005, and remained principal investigator until the project's completion.
William Abraham, M.D., a professor of internal medicine and heart failure cardiologist at Ohio State University, and Ileana L. Piña, M.D., a heart failure and transplant cardiologist, professor of medicine at Case Western University, and the creator of the National Heart Failure Training Program, provided advice on the program's design and execution. Margie Namie, R.N., M.P.H., vice president for chronic care management at Mercy Health Partners, one of CHP's regional networks, served as project manager during the first three years.
Target Population: This initiative sought to improve care for all heart failure patients treated at Catholic Health Partners hospitals and clinics. In addition, a targeted intervention at six hospitals focused on patients admitted with a primary diagnosis of heart failure and found to be at high risk for readmission or death. Patients were identified using a screening instrument that takes into account their clinical condition, as well as social risk factors such as unstable living situations and low education levels that put them at increased risk of hospitalization.
Key Measures: CHP assessed performance on the following measures across 22 of the health system's hospitals:
1. Four national, process-of-care quality measures for heart failure (now reported by nearly all U.S. hospitals on Hospital Compare):
- percent of patients given angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction;
- percent of patients given an evaluation of left ventricular systolic function;
- percent of patients given discharge instructions; and
- percent of patients given smoking cessation advice/counseling.
CHP's initial goal, set in 2002, was to achieve 75 percent success for each of these measures. From 2003 and on, the target was to achieve top decile performance on a composite of all four measures, based upon nationally available benchmarks.
2. Readmissions for any cause within 30 days of discharge among patients with a primary diagnosis of heart failure upon admission. In 2002, the readmission rate for HF patients among the 22 hospitals was 22 percent. CHP set a target readmission rate of 17.5 percent with a stretch goal of 15 percent.
The system's trustees evaluated all senior leadership and hospital CEOs on their progress toward the targets for these measures, in addition to other key metrics. A substantial part of their performance incentive was based on achieving these targets.
Implementation Timeline: In 2002, CHP won a Partnership for Quality grant from the Agency for Healthcare Research and Quality (AHRQ) for its HF GAP project. These grants were provided to 22 institutions nationwide to support projects that accelerate the adoption of practices that have been shown to improve patient care.
The AHRQ grants encourage participants to forge partnerships between researchers and practitioners. Catholic Health Partners' response was to include senior management, cardiologists, nurses, primary care physicians, and other specialists from the CHP health system, as well as heart failure experts from Case Western University and Ohio State University, on its leadership team. During the project's first year, the team reviewed the evidence on best practices for HF care, selected performance measures, and developed training materials for providers.
Beginning in 2002, CHP set system-wide goals to improve HF care and began measuring performance on the indicators described above.
In 2004, six CHP hospitals each hired a registered nurse to work in a newly created staff position as "heart failure advocates."
Process of Change: CHP sought to reduce the gap between the best clinical evidence for HF care—guidelines established by the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America—and actual practice. The project's leadership did not mandate that participating hospitals use a particular method to implement these guidelines. Instead, the hospitals chose the strategies and tools that best enabled them to achieve the performance goals.
Six CHP hospitals adopted an additional intervention.  They each recruited a registered nurse to serve as a heart failure advocate by guiding and promoting more consistent levels of guideline-based care for HF patients found to be at high risk for readmission or death. Heart failure advocates also developed and implemented broader organizational initiatives to improve HF care, such as provider-based educational events and medication-access programs. The heart failure advocate concept arose from discussions among CHP caregivers, who noted that many HF patients needed help coordinating their care among specialists, primary care physicians, home health providers, and family caregivers.
"We had to make it clear that advocates would function very differently than traditional hospital case managers, who tend to focus solely on discharge planning," says Casey. "Their job would not be to collect quality data for the hospital; we saw them as expertly informed, credible, and reliable care coordinators between providers and patients."
The advocates' training program combined clinical information with communication and management skills. Participants attended a two-day session offered through the National Heart Failure Training Program, which Piña created in 1995 and later customized for this initiative. Namie identified advocates' learning needs through a skills assessment process and connected them with appropriate resources. Overall, their training focused on:
- physiology and causes of heart failure;
- evidence-based approaches to medication adherence and management, especially for ACE-ARB inhibitors and beta blockers;
- patient-centered care coordination techniques that go beyond traditional case management, with special emphasis on post-discharge follow-up and communication with providers responsible for outpatient care; and
- leadership skills, effecting change, problem-solving, and conflict resolution.
Using case studies, the advocates explored clinical profiles and complicating factors, such as physicians who resist nurses' suggestions or family caregivers who don't want to change complex medication regimens. "The case studies helped advocates think through how they could effectively overcome barriers on an individual patient level," says Namie.
Advocates also helped to raise awareness of heart failure within the hospitals and to improve systems of care for these patients. This included educating patients and hospital staff about HF self-management, the importance of a low-salt diet, monitoring weight, medication reconciliation, and watching for symptoms that indicate decompensation.
They learned to do "whatever it takes" to improve HF patients' quality of life, says Casey, from paying attention to behavioral strategies that increase medication adherence to addressing personal, financial, and social barriers. For example, advocates helped patients who could not afford their medications take advantage of pharmaceutical company programs that offer prescription drugs at low or no cost.
"Heart failure is a frightening diagnosis, and tends to come later in life when people are already dealing with other issues," says Namie. "All of a sudden they have to manage multiple medications, a completely different diet, and have to be active at a time when they may be feeling tired and wrung out. But we found that—with the help of the advocates—the vast majority of the patients were able to manage their condition."
The AHRQ grant initially paid the salaries of the six HF advocates, and continuing medical education programs spread the knowledge gained from this intervention to all HF community physicians and hospital staff. Once the funding ended, three CHP hospitals chose to maintain the HF advocate positions and one, St. Rita's Medical Center in Lima, Ohio, created an advocate position for diabetes patients.
Results: Among the 22 hospitals, performance on a composite of the four Hospital Compare heart failure measures showed statistically significant improvement every year between 2002 and 2006, ultimately reaching 95 percent (Figure 1). Several individual CHP hospitals achieved top decile performance nationally for these measures. Performance levels improved on the opportunity measure, which is calculated by dividing the total number of achieved interventions by the total number of opportunities to achieve them. Performance also improved on the appropriate care quality measure composite, which calculates the proportion of HF patients receiving 100 percent of the care for which they were eligible.
Aggregate all-cause HF readmissions within 30 days also decreased among the 22 hospitals from 22 percent in 2002 to consistently below 20 percent between 2004 and 2006. Notably, there was a 40 percent decline in inpatient mortality for all HF patients admitted to CHP hospitals during the same period, suggesting an important linkage between care processes, systems changes, and outcomes.
A separate analysis was used to measure the impact of the heart failure advocates at four of the six hospitals that implemented this intervention. (The two other hospitals did not have sufficient staff available to provide the necessary data.) The outcomes for 405 patients followed by HF advocates were compared with 1,974 patients who received usual care. This analysis included all heart failure patients who did not expire during the evaluation period or leave the hospital against medical advice. The data suggest that heart failure advocates had a strong positive effect on the risk of subsequent hospitalizations: when compared with baseline rates, the patients they cared for were five times less likely to be readmitted within 30 days for any cause than patients who were not enrolled in the program (Figure 2). Hospital costs were also substantially lower for patients supported by heart failure advocates, according to the analysis.
Implications: Setting organizational goals to achieve top national performance and rewarding senior management for successful clinical quality improvements are powerful motivators of change. "Adhering to nationally standardized, evidence-based clinical guidelines is crucial for advancing quality care, but health care providers need to focus on valid performance measures in order to achieve the highest levels of improvements in that care," says Casey. "Many have spent their efforts trying to translate guidelines into practice tools. But properly constructed performance measures, such as those used in this HF GAP initiative, give physicians and hospitals creative leeway to get to top performance, while also letting them know whether their quality improvements are actually helping patients."
Giving hospital providers access to academics who specialize in heart failure research and treatment can also help to spur change. "CHP's physicians and nurses obviously understand the science of heart failure," says Casey, "but it was a great psychological and morale booster to have ready access to nationally recognized, state-of-the-art expertise for the good of their HF patients."
The intervention also found that nurses can be trained as heart failure advocates and do not need an advanced practice degree to improve HF care and help reduce readmissions among these patients. This is important because many regions of the United States have a limited supply of advanced practice nurses, making the use of specially trained registered nurses for care coordination programs more feasible than the use of advanced practice nurses.
Better management of chronic conditions is likely to lower overall costs to the health system, but current payment policies create few incentives for hospitals to invest in it. In fact, hospitals may lose money by investing in programs that reduce the number of hospitalizations, because most are not reimbursed for their efforts and they stand to lose business as hospital admissions decline.
Still, under the current Medicare payment system, treating acute, decompensated heart failure is minimally or not at all profitable for most hospitals, say Casey and Piña. Therefore, appropriate incentives, such as a shared savings approach, could encourage hospitals to focus on heart failure management. Further research is needed to explore the potential return on investment from care management programs for heart failure and other chronic conditions leading to frequent hospitalizations.
CHP's efforts have particular salience given that the Joint Commission and the Centers for Medicare and Medicaid Services are increasingly focusing on readmission rates as a marker of hospital quality, and the National Quality Forum is set to vote on new consensus standards for hospital readmissions, including one for heart failure similar to that used in CHP's HF GAP initiative. If Medicare and/or other payers begin to curtail payments for certain kinds of readmissions, more hospitals may be encouraged to focus on the intersections between acute and chronic care.
For Further Information: Contact Donald Casey at [email protected]
 M. Jessup and K. M. McCauley, Heart Failure: Providing Optimal Care (First Edition), Published Online: 16 Nov 2007.
 The hospitals were: Community Health Partners (Lorain, Ohio); St. Charles Mercy Hospital (Oregon, Ohio); St. Elizabeth Health Center (Youngstown, Ohio); St. Rita's Medical Center (Lima, Ohio); Mercy Hospital Clermont (Cincinnati, Ohio); and St. Elizabeth Medical Center South (Edgewood, Ky.).