Reducing Heart Failure Readmissions Through a Shared Medical Appointment

INTRODUCTION: In March 2018, the Orlando Veterans Affairs Healthcare System (OVAHCS) heart failure (HF) readmission rate was 30.4%, notably higher than the national rate of 17.3%. The HF Team manages NYHA III and IV patients (1,000 of 3,500 at OVAHCS) and was unable to see patients within 14 days of hospital discharge. Many patients were being discharged with a limited supply (7 days) of newly adjusted medications resulting in an inadequate supply to last until the patient's post-discharge follow-up appointment. GOALS: Improve clinic access and develop a multidisciplinary treatment approach by providing focused education, linking high risk patients with beneficial resources, reducing patients lost to follow-up, ensuring timely medical support to improve HF self-management and reducing admissions. METHODS: The HF Program implemented the use of a Shared Medical Appointment (SMA) to target these high-risk patients, focusing on non-adherent, frequently admitted or those at risk for future admissions. The SMA was offered every 2 weeks allowing patients to be seen within 14 days of discharge. The SMA included comprehensive care that targeted education, behavioral change, and medical intervention (e.g., exam, medication changes, refills). Consults to supportive services (e.g., clinical pharmacist, clinical psychologist, dietician, telehealth, educational classes) were offered. The SMA visit also aligned with Cardiology Clinic IV diuresis appointment slots in effort to avoid preventable admissions. RESULTS: From August 2018 to April 2019, all patients targeted for the SMA were offered an appointment within 14 days of discharge. Only 8% of those seen in SMA were readmitted compared to 28% of those seen in a traditional HF team follow-up appointment. Through the SMA, an average of 2.5 consults per Veteran were placed to facilitate improved HF management. Additionally, 97% of patients required medication alterations to avoid re-hospitalization, 50% required equipment to self-monitor symptoms, 78% were referred to a Cardiology PharmD for medication optimization, 41% engaged in treatment with a clinical health psychologist to focus on health behavior, and 36% joined HF Education Classes for additional learning opportunities beyond SMA. CONCLUSIONS: Participating in the HF SMA greatly reduced the likelihood of being re-admitted within 31 days when compared to traditional Cardiology HF visits. The group setting and brief exam aspect of the SMA improves efficiency by providing care to more Veterans at once than would be possible if done individually. Patients seen through the SMA were able to be seen within 14 days of hospital discharge. Including more providers and offering SMAs more frequently may help reduce re-admission rates to a greater number of patients.