There's just two days left before the official launch of Hospital to Home, ACC's quality initiative to reduce 30-day all-cause, risk-adjusted readmission rates for heart failure or AMI by 20 percent nationally by 2012. Check out this video with Harlan Krumholz (following his blog post here). Also, don't forget to enroll in the initiative and register for Thursday's launch Webinar (1 p.m. EDT) at http://www.H2HQuality.org.

Today’s post comes to us from Harlan Krumholz, M.D., F.A.C.C., the Harold H. Hines, Jr., professor of medicine at the Yale University School of Medicine. Harlan is a well-known leader in advocating for improvements in cardiovascular quality. Not only did he lead ACC’s successful quality improvement program “D2B: An Alliance for Quality,” he currently serves as the co-chair of the Hospital to Home (H2H) steering committee. Outside of his work with the ACC, Harlan is also heavily involved in the Centers for Medicare and Medicaid Services’ efforts to develop national measures for public reporting of hospital performance.

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Over the last several decades, the cardiology community has led our profession in generating new knowledge and seeing it applied for the benefit of our patients. Recently, we dramatically improved door-to-balloon times – moving in rapid progression from an era where only one-in-three patients were treated within the guideline-recommended 90-minute timeframe to now, where almost 90 percent of our patients are treated within that benchmark. Remarkable.

Another chance to lead lies before us. On Oct. 22, the ACC, in partnership with the Institute for Healthcare Improvement, will launch a major quality improvement initiative called Hospital to Home (H2H)… this time focusing our quality efforts on readmission rates. Currently, about 20-25 percent of our patients hospitalized with an acute myocardial infarction (AMI) or heart failure are back in the hospital within 30 days. Many of these admissions are preventable through improvements in the transition from inpatient to outpatient status. Unfortunately, we have often neglected this vulnerable transition period for patients.

Gaps in Care
We have many obvious gaps in care – patients often leave without information about the hospitalization being transmitted to other caregivers in a timely way; without access to medications; without appointments being set; and without an emergency plan for if their condition suddenly worsens. Studies have shown since the 1990s that improving the handoff between the hospital and the “home” can lead to a reduction in readmissions by addressing these gaps. Our fragmented health care system places many barriers in front of health care providers in putting known methods into practice. To reduce readmission rates, we’ll need to make special efforts to focus on transitions and most importantly – to focus on the patient, specifically, making efforts to ensure that the patient is ready and knowledgeable enough to manage their care – and that the system is poised to provide the support they need.

H2H Goals – Just the Beginning
H2H will assist providers in overcoming the systemic barriers to improving readmission rates. The initiative is committed to reducing 30-day all-cause, risk-adjusted readmission rates for patients with a diagnosis of heart failure or AMI by 20 percent nationally by 2012. In HF, that would take the rate from about 25 percent to about 20 percent. This goal is ambitious – but we aspire to produce a substantial benefit for patients.

H2H will leverage other national initiatives contributing to a reduction in readmission rates and will harness the collective knowledge, creativity and energy of its key strategic partners -- Kaiser, the Veterans Administration, the American Hospital Association, The Joint Commission, PREMIER, HCA -- and others to reach this goal. In my opinion, the 20 percent reduction is just the beginning of what we can achieve through our collaborative efforts. The path is more challenging than ever because of our goal of actually affecting patient outcomes, but we are bringing together expertise, resources, tools and a mechanism for us to learn from each other to meet this goal.

For those of you who want to be part of this effort, you will not be alone. We already have more than 250 facilities (e.g., hospitals and medical practices) that have joined us. Teams will be anchored at hospitals but will stretch across the continuum of care. We will track progress and, ultimately, assess whether we decreased preventable readmissions through improved care. We want this effort to equip teams for success.

Join Us in Reducing Preventable Readmissions
For more information, visit: http://www.h2hquality.org/, or email hospital2home@acc.org. H2H officially launches Oct. 22 with a Webinar explaining the initiative in greater detail. To join the Webinar, please register in advance online. If you are unable to attend on Oct. 22, you will be able to access the Webinar archive through our Web site.

We want to again show the nation that the cardiovascular community knows how to get results for our patients. We hope you’ll join us for this exciting initiative.

* Dr. Krumholz's post is part of a monthly series of guest posts by ACC leadership. Check back next month to see which ACC leader is sharing his or her thoughts on health care reform!

The Senate Committee on Health, Education, Labor and Pensions (HELP) last week outlined its broad goals for reforming the American health care system. Among the top goals: improving the delivery system; enhancing prevention and wellness; reducing fraud and abuse in public and private health systems; and establishing shared responsibility for financing of reform efforts. Nobody can argue with the goals, but how the heck do we get there? We’ll need more details and some HELP.

The Committee appropriately suggests that health care reform legislation should encourage adoption and use of health IT; promote evidence-based medicine; facilitate health literacy; and include strategies for tackling preventable medical errors and hospital readmissions. It also proposes better managing chronic conditions through care coordination, medical homes and community health teams. Again—we agree. I mean, duh.  But, how do we systematically do that? ACC is working with leaders in the Senate and House as they continue to flesh out these and other proposals and develop overarching health reform legislation. For the latest information on health reform, visit http://qualityfirst.acc.org.

Meanwhile, President Obama met this week with key Democratic Senators Baucus and Kennedy and reaffirmed his support for the creation of a government-sponsored “public plan” health insurance option — the issue that invokes the most angst and opposition from Republicans who might otherwise support some kind of overarching health reform legislation (as an alternative to national bankruptcy?). Read more in the New York Times and The Washington Post. 

For me, it’s what is not in these articles and stories that is most concerning. Consider the following:

IF the SGRrr payments are flat for ten years as projected, how do we prevent tens of thousands of doctors from just throwing in the towel, exacerbating the access problem? If we move the delivery system toward integrated groups, and transform payment from fee-for-service to bundling or episodes of care (or capitation) to align payment incentives with quality improvement, who receives and distributes the payment bundles?  Hospitals? New entities?  If the money goes to hospitals to dole out to doctors, should doctors all be employees of hospitals to be able to share in the huge profits hospitals make from? Or could bundles go directly to doctor groups? If so, how would they be organized if not already in integrated systems? And, if any of this is going to work in terms of payment incentives, gainsharing, and new potential relationships between physician specialties and hospitals, isn’t some anti-trust relief going to be needed? Is that part of the reform plan?

And, where is the med-mal relief plan that we will need to reduce defensive medicine costs? And, what if a new public plan is created that pays less than what it costs for some doctors to produce the required care? In the current Medicare program, it is illegal to balance bill patients to cover costs. Will a future potential Medicare-for-all concept of Medicaid, the new ‘public plan,’ and Medicare allow doctors to opt out--or will we be forced into a kind of pseudo-public employment? If the new public system were to become untenable and unfair in terms of reimbursement (let’s say the government has some budgetary problems in the future?), would doctors be prohibited from opting out of the program and still seeing patients who were willing to pay them directly?

And what about EMTALA? If health reform achieves universality, is EMTALA to be sunsetted? Do on-call stipends go away? Why or why not?

None of these ‘details,’ among many, many others, are currently included in the emerging principles of reform discussions. It’s a little scary. We really need to think about these details. It seems to me that after we pass whatever we pass this year, we’re going to have a year or two of very messy details and divisive issues to deal with.   

From the Senate perspective the SGRrrr elimination appears less likely this week. As you may recall, Mr. Baucus and the Senate Finance Committee last week proposed a $38 billion, three-year band-aid (a continuation of the past failed approach), but he told me last week at a breakfast meeting that he thinks they can muster together $150 – $200 billion from somewhere (cancellation of the war in Afghanistan?) to get closer to eliminating it. The Administration breakthrough decision to shift the $87 billion of injectable drug costs embedded in SGR from Part B to Part D of Medicare would make the total fix more likely.

The House (Pelosi, et al) still seems committed to look for the complete fix this year, but the Senate doesn’t see how it would be paid for (but hey! If SGRrr goes away, what formula would we use? Why not apply the Medicare Economic Index that the hospitals and the rest of the system use? This seems to provide annual increases that fairly closely approximate increases in the cost of doing business).

Keep in mind that even if Congress finds $280 Billion, physicians would not receive any pay increase over the next 10 years without additional funds. The SGR fix simply eliminates the overt pay cuts. Since business costs nonetheless continue to rise, new payment options for quality are also essential in this reform process. While Baucus insists the Physician Quality Reporting Initiative (PQRI) must continue, the quality improvement bonus attached in the current proposals are likely to be no more than 2 percent, hardly enough to motivate the extra work hours and workflow changes practices need to accomplish to effectively participate.

The ACC and IHI (Institute for Healthcare Improvement) Hospital-to-Home (H2H) project is generating great interest. This may be the kind of direction — one that unfortunately most of our members do not yet appreciate — that is the only pathway toward needed payment reform and payment increase that could keep pace with rising costs of business for practices. Given the rising tide to create reform this year, we will need some Patrick Henrys to ride through all of our chapters and states to let people know big change is coming -- and won’t be a tweak of the status quo. Reform doesn’t necessarily have to come out badly -- but need to make sure we stay at the table.

*** Image from Flickr (vtengr4047). ***

On Friday, the Centers for Medicare and Medicaid Services (CMS) released to all U.S. hospitals their performance on six key measures, in preparation for public announcement of these measures this summer.  The measures: 30-day mortality and 30-day readmissions for heart failure; acute myocardial infarction; and community-acquired pneumonia.

Hospital to Home
"Hospital to Home" -- a new partnership between the ACC and Institute for Healthcare Improvement -- is moving along swiftly, as a way to help our members reduce CV hospital readmissions. CV hospital readmissions are currently at 25% of discharges within 30 days. 

Though our Hospital to Home (H2H) project, we aim to reduce 30-day all-cause readmissions for heart failure and AMI by 20% nationally by December 2012.  The project will officially launch when the CMS measures are publicly released this summer.  Watch the video below for more info.

One of five Medicare beneficiaries discharged from the hospital is readmitted within 30 days, according to the Commonwealth Fund. Half of patients admitted for reasons other than surgery are readmitted without having seen a doctor in follow-up. The study appeared in the latest issue of the New England Journal of Medicine and shows these hospital readmissions cost Medicare $17.4 billion in 2004. Wow.

Heart failure readmissions account for the biggest chunk of that. Our new Hospital-to-Home (H2H) initiative with the Institute for Healthcare Improvement (IHI) could mean savings on a massive scale for heart failure and coronary artery disease. H2H aims to reduce preventable readmissions by 20 percent by 2012 for HF and CAD. We’ll give hospitals and physicians tools and strategies to help educate patients and ensure they follow up with physicians, adhere to medications and improve outcomes in the outpatient setting.

H2H got major media attention at ACC.09, resulting in great early coverage:

• Wall Street Journal: "Cardiologists Set Heart-Failure Treatment Program"
  
  
• MedPage Today: "ACC: Cardiologists Plan to Cut Heart Failure Hospital Readmits by 20%"

Tomorrow in Room W101, ACC.09 will feature a “D2B: Sustain the Gain” symposium featuring experts in the field discussing current topics in STEMI care. If you’re asking yourself right now: I thought it was called “D2B: An Alliance for Quality?” – you’re right, it was. “D2B: Sustain the Gain” represents Phase 2 of the campaign. Since Phase 1 (An Alliance for Quality) was such a success [go to the Participant’s Workshop tomorrow morning, from 7 – 9 a.m. at the Rosen Centre Hotel, Salon 3, to hear why], the ACC is using D2B: Sustain the Gain to figure out how we can maintain those gains. It’s clear that there are many challenges inherent in sustaining D2B times of 90 minutes or less. We’ll be developing materials and support tools that hospitals need to continue their success.

Quality efforts like D2B are crucial in making a difference in health care reform efforts. The federal government doesn’t have to tell cardiologists to improve quality – cardiologists are working together to do it themselves. Through D2B, we’re making serious in-roads in improving quality – and I know from my visits to the Hill, lawmakers are taking notice.

Meanwhile, stay tuned this summer for the ACC’s newest national quality improvement initiative, Hospital to Home (H2H). With H2H, we’ve set a measurable goal of reducing the 30-day all-cause readmission rate for patients with heart failure or heart attack by December 2012. To register for this program in advance visit: www.acc.org/h2h/enrollment. This is an exciting opportunity to improve patient care and reduce preventable and costly readmissions. We have a great partner in IHI for this initiative as well.