Cardiovascular Disease Has a Signiﬁcant and Widespread Impact on Patients
- People with high cholesterol have twice the risk for heart disease3
- Fewer than half of adults with high LDL-C are getting treatment1
There Are Costly Financial
Implications as Well
Care Gaps: Contributing Factors to CVD Have Room for Improvement
According to CMS Hospital Compare
- National HF and AMI patient readmission rates are 21.6% and 16.3%, respectively1
- National HF and AMI patient mortality rates are 11.9% and 13.6%, respectively2
In the us adult population
- HEALTHY DIET
- PHYSICAL ACTIVITY
Who Are the Quality Care Stakeholders in CV Health?
|CMS 5-STAR (2018)1|
|Controlling Blood Pressure||Improving or Maintaining Physical Health|
|Medication Adherence for Hypertension (RAS antagonists)||Monitoring Physical Activity|
|Medication Adherence for Cholesterol (Statins)||Adult BMI Assessment|
|Medication Reconciliation Post-discharge|
|NCQA HEDIS® (2018)2|
|Controlling High Blood Pressure||Statin Therapy for Patients with Diabetes|
|Statin Therapy for Patients with Cardiovascular Disease||Physical Activity in Older Adults|
|Persistence of Beta-Blocker Treatment After a Heart Attack||Medical Assistance with Smoking and Tobacco Use Cessation|
|Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia||Adult BMI Assessment|
|Follow-up After Emergency Department Visit for People with High-risk Multiple Chronic Conditions||Plan All-Cause Readmissions|
|Transitions of Care||Hospitalization for Potentially Preventable Complications|
|Metabolic Monitoring for Children and Adolescents on Antipsychotics|
|Statin Therapy for the Prevention and Treatment of Cardiovascular Disease||Preventive Care and Screening: Body Mass Index Screening and Follow-Up|
|Controlling High Blood Pressure||Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention|
|All-cause Unplanned Admissions for Patients with HF||Risk Standardized, All Condition Readmission|
|IVD: Use of Aspirin or Another Antithrombotic||Skilled Nursing Facility 30-Day All-cause Readmission Measures|
|All-cause Unplanned Admissions for Patients with Multiple Chronic Conditions|
|Rate of Readmission for CABG Surgery Patients||Death Rate for CABG Surgery Patients|
|Rate of Readmission for Heart Attack Patients||Death Rate for Heart Attack Patients|
|Rate of Readmission for HF Patients||Death Rate for HF Patients|
|Rate of Readmission for Stroke Patients||Death Rate for Stroke Patients|
|Excess Readmission Ratio for Heart Attack Patients|
|Excess Readmission Ratio for HF Patients|
|Excess Readmission Ratio for CABG Patients|
|MACRA QUALITY PAYMENT PROGRAM5|
|Hypertension: Improvement in Blood Pressure||Documentation of Current Medications in the Medical Record|
|Statin Therapy for the Prevention and Treatment of Cardiovascular Disease||Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention|
|IVD: Use of Aspirin or Another Antiplatelet||Preventive Care and Screening: BMI Screening and Follow-up Plan|
|Controlling High Blood Pressure||Care Plan|
|Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented||Use of High-risk Medications in the Elderly|
|CAD: Antiplatelet Therapy||Cardiac Rehabilitation Patient Referral from an Outpatient Setting|
|CAD: Beta-blocker Therapy—Prior MI or LVEF < 40%||Persistent Beta-blocker Treatment After a Heart Attack|
|HF: ACE Inhibitor or ARB Therapy for LVSD||Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling|
|HF: Beta-blocker Therapy for LVSD|
|IVD All or None Outcome Measure (Optimal Control)|
A Case of Improved CV Health—St Luke’s Hospital, Cedar Rapids, IA
In 2006, St. Luke’s Hospital demonstrated a 25% readmission rate for patients with HF. Hospital leadership believed that reducing the HF readmission rate was a signiﬁcant opportunity for improvement, as it aligned with the hospital’s strategic plan to deliver demonstrably better care to patients.
After assembling a Heart Failure Team, St. Luke’s also joined the Institute for Healthcare Improvement’s (IHI) Transforming Care at the Bedside collaboration in an effort to
Reduce preventable hospitalizations for patients with HF, aligning with the hospital’s strategic plan to produce care of demonstrably better quality
Develop data analytics, performance improvement, clinical integration, and other competencies critical to value-based reform
Cross-continuum participation and alignment
- Engaging, involving, and empowering a wide range of stakeholders to be honest and active participants in the care redesign process
- Pursuing a patient- and family-centered approach with guidance from its in-house Patient/Family Advisory Council
- Fostering meaningful partnership and engagement with physicians
Standardized tools and compatible information infrastructure
- Ensure that patients receive coordinated care as well as uniﬁed, consistent, and reinforcing messages from all sources
- The Heart Failure Team reviewed and revised the hospital’s patient education materials, and developed an enhanced teaching and learning strategy for coordination across all care settings
- Implementing “Teach-back,” in which patients are asked to recall and restate in their own words what they were just taught by the provider, then tracking the rates of accuracy
Horizontal leaders and executive sponsorship
- Identified horizontal leaders: individuals who could identify system-wide trends and work effectively across disciplines and care setting to address patients needs as a central element of the desired leadership capability
- Established a formal executive sponsorship system to establish personal accountability for program performance on the executive level, as leadership support and guidance were important to the initiative’s growth, scale, and diffusion
Rapid learning from external and internal sources
- Identify, adopt, and refine concepts from other departments, organizations, and practice areas and use them to reduce readmissions
- Outside learning: capitalized on learning opportunities available through IHI and other health care institutions, accounting for both evidence-based successes and lessons from others’ difficulties
- Internal sharing: looked internally for concepts, care models, and strategies that could help to reduce readmissions, such as complementary in-home visits
HF READMISSIONS (FOR ANY CAUSE) WITHIN 30 DAYS30-day readmission rate for patients with HF (any cause) was reduced from 25% in 2006 to 15% in 2011
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