Demonstration Project Using Technology to Improve Health Outcomes for Hospitalized Patients With Heart Failure Discharged to Skilled Nursing Homes

The clinical course of heart failure (HF) is highly variable, but most patients eventually require hospitalization to manage symptomatic exacerbations. As HF progresses, hospitalizations become increasingly frequent as overall function and health decline. After an acute hospitalization, many older patients are discharged to skilled nursing facilities (SNF). Patients discharged to SNF after a HF hospitalization experience rates of death and re-hospitalization that are substantially higher than similar patients who are discharged home, even after adjusting for patient factors. The risk of worsening HF is highest in the first week after hospital discharge. Close monitoring of a patient during this vulnerable period could allow early detection and treatment that would avert clinical deterioration and the need for re-hospitalization; however, patients do not routinely receive cardiac specialty care while in SNF for many reasons, including patient immobility, limited transportation options, under-trained staff, competing medical conditions, and lack of timely access to cardiologists.

This research will address the issues associated with heart failure using a multi-faceted intervention consisting of provider, patient, and caregiver education and training, peer-to-peer telephone support for SNF staff, improved access to specialty care to include telemedicine evaluation by HF specialists, and early follow-up following SNF discharge. Specifically: Study the effect of a telemedicine disease management intervention in older patients with HF (either as a primary OR secondary diagnosis) discharged to a SNF from Providence St. Vincent Medical Center (PSVMC) after a cardiac-related admission.

Multiple benefits are anticipated from these interventions. First, a close partnership between the staff at the SNF (Marquis Hills) and the Providence Heart Clinic will be fostered. A major focus early in this partnership will be teaching SNF personnel how to assess signs and symptoms of HF, how to promote patient education and self-management ("teaching the teachers"), and how to use an existing HF disease management tool ("HF Zone tool"). Second, heightened monitoring of patients during the period of greatest risk for HF decompensation is expected to improve care, efficiency, and patient outcomes and reduce costs. Earlier detection and intervention can mitigate worsening HF, as well common complications of HF therapies, such as kidney dysfunction and electrolyte abnormalities. Third, this novel use of telemedicine could radically alter the approach to chronic disease management in care facilities, where specialty care is not readily available even for a high-risk population. Fourth, the use of telemedicine enables the intervention to be scaled easily to other SNFs and clinics and other chronic conditions.

Patients being discharged to Marquis Hills SNF will be identified by case management prior to discharge and consented for enrollment in the study. A Heart Failure clinician, will assess the patient's baseline capacity for self-care for HF (Self Care of Heart Failure Index, SCHFI), and quality of life (Kansas City Cardiomyopathy Questionnaire, KCCQ).

Intake and data collection at SNF will involve baseline assessment of HF symptoms and basic physiologic parameters (weight, blood pressure, heart rate) using the HF Zone tool. Certified nursing assistants will provide basic education on management of heart failure to patient and their families. The first business day following SNF admission, cardiology nurses will contact the SNF staff to review the daily HF Zone tool findings and follow-up any laboratory testing.