Congestive heart failure (CHF) is a progressive disease that targets the heart muscle and its ability to pump blood; it prevents the heart from pumping blood as required. It specifically refers to the situation in which there is fluid build up in the heart, reducing its ability to pump it efficiently (Mahabir et al., 2020). Social determinants of health (SDOH) are conditions or factors, such as socio-economic status and education, that may cause health inequalities in a population (Anand et al., 2016). These determinants have an impact on a wide range of health risks and outcomes and have been associated with a wide range of health conditions. Due to the high 30-day readmission rates in patients with CHF, an assessment of these determinants and their impact is necessary. This project will focus on establishing an SDOH tool in the EMR that will be used to decrease the readmission rates after 30 days for patients who have CHF.
With this project, the change in clinical practice that is being anticipated is establishing or outlining a standardized tool that can help in the early identification of SDOH, which places CHF patients at high risk for readmission. The project will also change practice by enabling collaboration with and reference to appropriate disciplines for better patient outcomes and increasing patient quality of life. Ultimately, the main contribution that the project will expect to make will be to decrease the 30-day rate of readmission. Based on this expected change in practice, there will be several expected impact outcomes. One of these impact outcomes is a decrease in the 30-day readmission in heart failure patients within health organizations. Secondly, the project will outline a useful SDOH tool being implemented in the EMR along with the ability to detect early SDOH risk stratification processes. The last outcome will be to create the ability to frontload support and are while increasing agency star ratings and patient satisfaction ratings.
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Background and Significance
Patients suffering from acute CHF often have to deal with high readmission rates (Mahabir et al., 2020). Once patients are discharged from skilled home care services, there is a very high likelihood of readmission after thirty days. This readmission often occurs due to a variety of factors that have an impact on the health of the patient (McKay et al., 2019). These factors include the absence of caregivers in the home to assist the patients and the inability to afford medication, which results in non-adherence to taking prescribed medication. The lack of transportation is also identified as interfering with follow-up with the poor financial status of the patient resulting in poor nutrition. These unaddressed psychosocial and socio-economic issues have an adverse impact on the health outcomes of acute CHF patients (Anand et al., 2016). They often result in readmission within 30-days, which may cause patient distress.
The high readmission rates for acute CHF patients not only have an impact on the quality of care provided to patients and their satisfaction but also adversely impact the funding the organization will receive. Increased readmission rates affect the patient and their satisfaction with the care that they receive. They result in the perception of a lower quality of care, which may result in poor health outcomes (Obuobi et al., 2021). The affordable care act has implemented a value-based purchasing program that supports communication and care coordination for the better engagement of patients and caregivers in discharge plants leading to a reduction in avoidable readmissions (CMS, 2020). This implementation evaluates excess readmission of six main medical diagnoses, with heart failure being one of the six (CMS, 2020). There will be a reduction in payments with increased readmission, which can result in the loss of profit and a decrease in the care quality being presented to patients.
Based on the ineffectiveness of the current practice used to provide care for patients suffering from acute CHF, it is clear that there is a needed solution that addresses the psychosocial and socio-economic issues. Therefore, the VNAHG has to identify the extent to which the integration of an SDOH tool in the EMR will decrease the readmission rates of 3o days for patients suffering from acute CHF. This tool will be critical for communicating information on what factors affect the treatment of this population and help in providing an individualized treatment plan that will facilitate better health outcomes.
Needs Assessment
The Visiting Nurse Association Health Group (VNAHG) is among the leading not-for-profit, patient-centered, community-based, health care organization that exists in Central Ohio and New Jersey (VNAHG, 2021). Due to the high readmission rate in the CHF population, the organization is focused on using SDOH tools and the information obtained to promote better health. There exists a need to decrease the rate of readmission for CHF patients that the organizations serve with a focus on individuals within the low socio-economic communities and class. Currently, the only standardized practice for the care of patients that suffer from acute CHF is the provision of telehealth. This practice is not effective, and there are concerns in regards to the readmission rate within the CHF population at the VNAHG. While this is a voluntary service, it is not required or highly recommended. The elevated rates of readmission are a growing concern, and the organization plans to try and focus on the SDOH and how to utilize this information for the promotion of better health. The use of the SDOH to stratify risks will be essential in enhancing the patients’ quality of life and increasing the health outcomes of CHF patients.
A SWOT analysis of the hospital environment further highlights the existing need for an SDOH tool that can minimize readmission rates for CHF patients. One of the main strengths of VNAHG is that the organization has all the necessary facilities and resources needed to provide proper care and treatment for patients suffering from CHF. In addition, the organization has access to the needed information and facilities that it can use for the provision of high-quality care. However, a major weakness is its use of the telehealth practice, a standardized process that is not effective in decreasing the readmission rate for CHF patients. The availability of SDOH information is an opportunity that healthcare providers can take advantage of to enhance the quality of care. The SDOH information can highlight factors that affect the health condition of patients with acute CHF to create a treatment plan that mitigates the impact of these factors. The impact of high readmission rates on the standard of patients’ care and the organization star ratings act as a threat. High readmission rates adversely impact the satisfaction of patients concerning the care provided to them (Anand et al., 2016). Quality measures and star ratings place VNAHG in a position to provide the best quality care for patients. The low star ratings will have an adverse monetary impact on the organization and decrease the referral process. Hence, the use of an SDOH tool will not only strengthen the services provided to acute CHF patients but also ensure that VNAHG can continually provide needed care to its patients. By decreasing the rate of readmission of acute CHF patients, the SDOH tool will improve the quality of health outcomes and enhance the satisfaction of patients concerning the care provided.
Problem/Purpose Statement
Heart Failure (HF) is among the leading causes of hospitalization in individuals that are aged 65 years and above in the United States. According to Medicare reports, more than one million individuals in the US are hospitalized per year with the primary diagnosis of heart failure (Mahabir et al., 2020). While there has been an improvement in the results with medical therapy, the rates of admission following hospitalizations from heart failure, hospitalization is still high within six months of discharge, with both unaddressed psychosocial and socio-economic issues as mitigating factors (McKay et al., 2019). Some noted concerns are a low level of adherence and compliance with medications, self-monitoring, and medical follow-up with medical professionals.
Patients that are admitted to skilled homecare with HF are noted to be readmitted on multiple occasions within a 60-day episode. These readmissions are identified to be an outcome of the result of the unaddressed SDOH and not the actual systemic cause of the medical diagnosis alone. It was found that the HF population that were readmitted did not have caregivers within the home to assist patients and poor financial status, which resulted in improper nutrition. The Centers of Medicare and Medicaid Services (CMS) established a penalty that focuses on decreasing thirty-day readmissions and on factors that affect readmission risks. Patients that live in high-poverty neighborhoods with low socio-economic status are more likely than others to be readmitted (Evans et al., 2021). Readmission within 30 days not only causes heightened distress and frustration in patients but also causes financial losses for the healthcare institution. Currently, the only standardized practice for the care of patients suffering from Acute Congestive Heart Failure is providing telehealth. This practice is not effective, and there exists concern in regards to the readmission rate within the CHF population.
This problem not only affects the patient’s satisfaction with care but also has an impact on the quality of care that is provided. Based on this problem, and the impact that it has on the health organization and the patient, there exists a need to stratify the risk of readmission and create a more individualized plan of care. This project will investigate how the early detection of SDOH could truly impact and enhance the quality of life while supporting better health outcomes. This investigation will involve an exploration of the extent to which the integration of a standardized social determinant health assessment tool in the EMR can decrease the readmission rates after 30 days in skilled homecare patients suffering from acute congestive health failure.
Clinical Question
The clinical question is identified based on the needs that have to be addressed and the expected outcomes of the project. Hence, the clinical question for this research will be:
To what extent does the integration of a standardized social determinant health assessment tool into the EMR decrease the 30-day readmission rate in skilled homecare individuals with Acute Congestive HF?
Aims and Objectives
The following objectives will be used to guide the project:
To establish an SDOH assessment tool that can decrease the 30-day readmission rate in skilled home care patients with acute CHF.
To access the extent to which the integration of an SDOH assessment tool in the EMR decreases the 30-day readmission rate in skilled homecare individuals suffering from acute CHF?
To increase the agency star ratings and patient satisfaction ratings in regards to care provided to acute CHF patients.
These objectives will be evaluated based on the following measures;
A decrease in the readmission rates after 30 days for skilled homecare patients with acute CHF.
A useful SDOH tool that can be implemented in the EMR.
An increase in agency star ratings to 3.5 or close to 5 and patient satisfaction ratings.
References
Anand, V., Garg, S. K., Koene, R., & Thenappan, T. (2016). National trends in hospital readmission rates in congestive heart failure patients. Circulation , 134 (suppl_1), A17286-A17286.
Centers for Medicare & Medicaid. (2020, November 18). Home Health Star Ratings | CMS . https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIHomeHealthStarRatings
Centers for Medicare & Medicaid (CMS). (2020, August 11). Hosp. Readmission Reduction | CMS . https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program
Evans, W. N., Kroeger, S., Munnich, E. L., Ortuzar, G., & Wagner, K. L. (2021). Reducing Readmissions by Addressing the Social Determinants of Health. American Journal of Health Economics , 7 (1), 1-40.
Mahabir, S. K., Olarte, N., & Palacio, A. M. (2020). The Impact of Social Determinants of Health on Heart Failure Readmission in a Veteran Population: A Single Center Study. Circulation: Cardiovascular Quality and Outcomes , 13 (Suppl_1), A262-A262.
McKay, C., Park, C., Chang, J., Brackbill, M., Choi, J. Y., Lee, J. H., & Kim, S. H. (2019). Systematic review and meta-analysis of pharmacist-led transitions of care services on the 30-day all-cause readmission rate of patients with congestive heart failure. Clinical Drug Investigation , 39 (8), 703-712.
Obuobi, S., Chua, R. F., Besser, S. A., & Tabit, C. E. (2021). Social determinants of health and hospital readmissions: can the HOSPITAL risk score be improved by the inclusion of social factors?. BMC Health Services Research , 21 (1), 1-8.
Visiting Nurse Association Health Group (VNAHG). (2021). About VNA Health Group. https://vnahg.org/about-vna/
Appendices
Appendix 1
Table 1 .0: Barnabas Health Homecare and Hospice SWOT Analysis
|
Strengths |
Weaknesses |
| Hospital has adequate facilities and resources. | The use of telehealth practice. |
| High accessibility of needed information. | Low level of satisfaction in patients. |
|
Opportunities |
Threats |
| Availability of SDOH information. | High readmission rates. |
| The use of an SDOH tool. | Low star ratings. |
