Return-to Hospitalization: A major problem for patients with CHF

Congestive heart failure (CHF) leads to more hospitalizations and readmissions than either pneumonia or heart attacks and CHF is estimated to be the primary diagnosis for one-quarter of patients in skilled nursing facilities.

Frequent, short-term admissions are a part of life for people living with CHF. Approximately a quarter of patients hospitalized with CHF will be readmitted within 30 days of discharge. This cycle of admission, discharge, and readmission adversely affects a patient’s quality of life and is costly to payers.

CHF is a condition in which the heart fails to pump enough blood to meet the body’s needs. Coronary artery disease decreases the nutrients and oxygen carried to heart muscle cells, causing them to weaken over time. High blood pressure forces the heart to work harder to deliver the same amount of blood to the body and lungs. Other causes of CHF include infections, kidney disease, past heart attacks, and obstructive sleep apnea. In many cases, patients have a combination of these comorbid conditions.

Typically, patients with CHF will have patterns of rapid decline followed by recovery. Catching them early in a potential period of decline can help prevent rehospitalization and other complications. Careful monitoring and attention to small changes in condition such as ankle swelling, edema, and weight gain are standard-of-care for managing CHF. SAIVA can help by monitoring nursing notes and surfacing subtle changes in a patient’s condition.

A Case Study: The Benefits of Early Prevention of CHF

Consider the following case study, which is based on true events but has been altered to protect the identity of the patient:

JW has long-standing diabetes mellitus, prior history of smoking, renal disease secondary to diabetes, and chronic obstructive pulmonary disease (COPD). He was diagnosed with CHF two years ago and has been in and out of the hospital many times. JW’s last hospitalization was approximately five weeks ago. Since discharge, JW has been ranked #1 on SAIVA’s Daily Risk Report.

Approximately one week prior to rehospitalization, JW had urinary incontinence, confusion, and increased weakness. JW’s confusion worsened over the next several days, and he became anxious and restless. As a result, JW was placed on 2-3 liters of continuous oxygen delivered via nasal cannula after a neuropsychiatric evaluation was requested.

Two days prior to readmission, JW developed coughing, wheezing, and shortness of breath that was worse when lying down. Lab results revealed that he had a markedly decreased red blood cell count. The new-onset respiratory symptoms, increased confusion, and anemia prompted a return to hospitalization.

JW’s hypoxia and anemia were most likely contributing to his confusion and some of the behaviors he was exhibiting. Transferring him back to the hospital is likely to exacerbate his confusion and anxiety further. It also puts him at risk for acquiring an infection, and it is costly to his health payer.

JW was hospitalized for one day before being discharged back to the nursing home.

Patients with CHF are Frequently Re-hospitalized

Signs and symptoms of CHF are commonly overlooked because of an elderly patient’s physical limitations. Shortness of breath and wheezing are more noticeable in ambulatory patients. Many patients with vascular disease are also experiencing some degree of dementia, which can make giving a medical history difficult. Finally, symptoms of CHF overlap with several other medical conditions, further complicating matters. Among the signs and symptoms to be on the lookout for are:

  • Increasing shortness of breath
  • Fatigue and weakness
  • Swelling and weight gain
  • Irregular heartbeat
  • Persistent cough or wheezing
  • Nighttime awakening to urinate
  • Confusion or decreased alertness

JW exhibited many of these signs and symptoms during the month between his discharge from hospitalization and his rehospitalization. As a result, he spent nearly a month on the SAIVA Daily Risk Report. The challenge is that many of these changes are incremental and easily missed.
Is CHF readmission inevitable or avoidable?

The Hospital Readmissions Reduction Program (HRRP) is a program instituted by the Centers for Medicare & Medicaid Services (CMS) to encourage hospitals to reduce readmission rates by improving communication and care coordination between hospital discharge planners and long-term care facilities. CHF is one of the six conditions CMS is focused on.

In 2021, CMS plans to fine 2,545 hospitals for having high readmission rates. Medicare defines readmission as any Medicare patient diagnosed with CHF, heart attack, pneumonia, COPD, hip or knee replacement, or coronary artery bypass graft surgery who is unexpectedly readmitted within 30 days. The average reduction in Medicare payments to these hospitals is 0.69%, with 613 hospitals receiving a penalty of one percent or higher.
We believe that the SAIVA for skilled nursing system empowers caregivers with the tools they need to intervene earlier in the course of CHF decline. Ultimately, having a CHF readmission prevention program in place, such as SAIVA’s, will significantly improve patient outcomes and reduce costs.

Data points, nursing notes, and lab values from patients like JW could be tracked long-term and between providers. Small changes can be detected and flagged for nurses to triage and take action. Using SAIVA to track and identify high-risk patients, our customers report that they have seen a 52% reduction in short-stay rehospitalizations and a 32% increase in resident days each year.

SAIVA optimizes its machine learning models using existing EHR data and the daily feed of new information. After training the model for two weeks, high-risk patients are identified and ranked with those most at risk at the top of the SAIVA Daily Risk Report. This report is delivered to your inbox, where you can investigate and act on it. The result—reduced hospitalizations, improved outcomes, and increased census —all key benefits for your facility, patients, families, and caregivers!

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