Nancy Roberts, the president and CEO of the VNA of Care New England and the executive vice president of Care Management at Care New England, was recently one of 10 health care professionals selected to participate in the first cohort of the Practice Change Leaders program.
Roberts’ efforts with the program will be focused on implementing a program emphasizing transitional care for patients with heart failure.
Providence Business News asked Roberts to talk about how her work fits within the changing health care landscape for Rhode Island and its aging population.
PBN: Your project at the Practice Change Leaders for Aging and Health will focus on the implementation of a transitional care model for patients with heart failure. What are the outcomes you would like to see?
ROBERTS: Outcomes will be achieved by recognizing that transitional care is essential to moving patients along the continuum of care in a safe, well defined, efficient, and effective manner while gaining consensus of different health care partners along the way. We have looked at best practices across the country and our own data from a collaborative effort with a patient-centered medical home that tested elements of transitional care. The 12-month project was supported by the Centers for Medicare and Medicaid Innovations Advisors Program and concluded in December.
One of the outcomes we will study in the Practice Change Leaders project is reducing preventable hospitalizations for heart failure patients. Statewide, over one-quarter of all admissions for Medicare beneficiaries are patients with heart failure. Multiple hospitalizations to treat exacerbations of heart failure are very common, however, many of these are preventable. With that said, it is important to note that while our goal is to avoid preventable rehospitalizations, we are not looking to discourage or prevent hospitalizations that are in the best interest of the patient.
In Rhode Island, more than one of every four deaths is related to heart disease and while death is not preventable, the events leading up to it and the patient’s overall quality of life certainly are.
This relates to the second outcome that will evaluate and measure the effectiveness of enhanced care transitions from one setting to the next. Through the development and implementation of patient self-management skills and competencies, we will evaluate effectiveness through quality of life measurement tools.
PBN: How does palliative care become integrated into the health care continuum for aging patients with heart failure?
ROBERTS: What a great and timely question! Dr. Kate Lally, a board-certified palliative care physician, recently joined Care New England and is working closely with VNA of Care New England as our director of hospice and palliative care.
We both agree there is a huge place for palliative care in the overall continuum of care for patients with heart failure. We are working hard to educate patients and their families who are struggling with heart failure, that palliative care should be a strong consideration along their individual care continuum for many different reasons, but most importantly, to enhance their quality of life.
One element of palliative care is understanding that every patient and family is different. Palliative care providers are trained to use their communications expertise to work one-on-one to help each individual understand what heart failure is, how it works, where it could lead and specifically, what it means to them.
PBN: What are the cost savings, if any, from matching the individual's care needs with his or her care setting?
ROBERTS: Nationally, among patients enrolled in Medicare, the rate of 30-day readmissions following hospital discharge with a heart failure diagnosis is close to 27 percent. In the Innovations Advisors Program pilot project, we saw rehospitalizations decrease by more than 40 percent to less than 18 percent over a nine-month period of time. This decrease accounted for an estimated $10,000 in cost savings per patient from preventable readmissions when a strong transitional care model was in place.
PBN: How is the model changing for ongoing medical care in the community in Rhode Island, from the perspective of VNA of Care New England?
ROBERTS: As health care providers we have traditionally worked in silos. The transformation to effective care transitions and true patient-centered care requires that we break down these silos and come together with a similar goal to do what is in the best interest of the patient through collaboration.
At VNA of Care New England, we have a long history of collaborating with our community health partners. Much of it has been by design, but also it is the very nature of what we do, provide home health care under the orders of a physician and keep them informed of any changes in the patient’s condition.
Additionally, we have been fortunate to develop strong relationships with many excellent physicians who have a keen understanding of effective transitional care. In Rhode Island, we are definitely seeing health care providers across the continuum becoming more collaborative to best serve the needs of the patient.
PBN: How important will population management analytics be a factor in determining future reimbursement for care for aging patients with heart failure?
ROBERTS: When we consider the elements of population management analytics to include care coordination across a population, in this instance heart failure, to improve clinical and financial outcomes through disease, case and demand management, I think you could say that we are making strides in the right direction.
However, we struggle with interoperability of health care information systems across different settings. For example, the electronic health record that we establish at VNA of Care New England for each patient may not be compatible with that of the hospital or physician and vice-versa.
Therefore, we continue to duplicate efforts in many instances to gain access to important patient data, negating some of the cost-savings and important value of the information exchange. This is an enormous challenge, but over time, I think that one that we will overcome.
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