Legacy Salmon Creek program reduces return of heart failure patients

By Marissa Harshman, Columbian health reporter

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Providers at Legacy Salmon Creek Medical Center enjoy helping people feel better, but they'd rather not see their patients again.

And thanks to a two-year-old initiative at the hospital, they're seeing some patients less and less.

Since implementing a new discharge checklist in April 2012, Legacy Salmon Creek has reduced its heart failure readmissions by 36 percent.

The checklist — which is evidence-based and driven by research — includes 23 criteria physicians, nurses, pharmacists and care managers use to determine whether a heart failure patient is ready to leave the hospital. The checklist includes medical criteria, such as minimum oxygen saturation levels and stable oral medication regimens, and patient education, such as counseling to avoid tobacco products, written instructions for salt restriction and plans for follow-up care.

The average heart failure readmission rate in the U.S. is about 23 percent. That means 23 percent of heart failure patients are readmitted to hospitals within 30 days.

In the 18 months prior to implementing the checklist, Legacy's heart failure readmission rate was 19.1 percent. In the first 18 months using the checklist, the hospital's rate dropped to 15.6 percent.

And the rate continues to drop. As of March, heart failure readmissions were down to 12.17 percent, said Dr. Hoa Ly, the medical director for Legacy Inpatient Medicine Service who led the effort.

"There's no going back," Ly said. "The early impact is amazing."

Medicine, in general, is physician-driven, Ly said. Physicians rely on their training and experience when treating patients. But since each physician has a different background, treatment is full of variations, Ly said. That includes when evaluating a patient for discharge from the hospital.

"This checklist helps us to focus our efforts and standardize what we do," Ly said.

Improving patient outcomes

Heart failure readmissions usually mean an increase in patient morbidity (rate of incidence of disease) and extra costs for the entire health care system, Ly said. Heart failure patients who are readmitted have typically not fully recovered from their previous stay. That means they arrive sicker and are likely to stay longer, he said.

Reducing readmissions provides a better outcome for patients, Ly said.

"The hospital is never a good place to be, unless you have to," he said.

In addition to the checklist, hospital staff have implemented other changes to help reduce readmissions.

For example, they created simpler take-home packets for patients. In the past, patients were given a thick packet with somewhat complicated information. Now, each heart failure patient gets a straightforward, three-page packet with bullet points and a daily symptom checklist.

A nurse or physician goes over the information in the packet with every patient before they leave and a case manager follows up with them after they leave the hospital, said Susan Frederick, a Legacy registered nurse case manager on the checklist development team.

"I can't change their age, their gender, their ethnicity. I can't change that they have heart failure," Frederick said.

She can, however, give them the information they need to keep themselves out of the hospital in a way they can understand, Frederick said.

Health reform spurs changes

The efforts to reduce readmission rates were prompted by the Affordable Care Act.

A program under the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with too many readmissions for three conditions: heart failure, heart attack and pneumonia.

Legacy Salmon Creek had its checklist in place well before the reductions began in January 2013 and will not be penalized for its readmission rates, Frederick said.

Ly and Frederick hope the hospital's success will encourage other hospitals to adopt similar practices.

The next step is to implement the checklist throughout the entire Legacy Health system. Frederick and Ly have also met with the leadership at PeaceHealth Southwest Medical Center and Kaiser Permanente and have presented their results at medical conferences.

But Ly and Frederick aren't the only ones encouraged. The rest of Legacy's staff has been pleased by the success of the checklist.

"The staff know the patients," Frederick said. "It's a very personal relationship with patients, and they're happy to see benefits."