Transitions of Care in Heart Failure

About the Project

Through interviews with multiple hospitals and outreach to national organizations, the KC QVIC has identified three key strategies hospitals may choose to deploy: 

CODEHF: Patients with heart failure who have worsening shortness of breath often present again to the Emergency Department (ED). CODEHF is a process of implementing a care pathway that supports rapid diagnosis and treatment, supplemented with prospective risk stratification to identify whether patients should be admitted or can be safely discharged home with early cardiology follow-up. At four Saint Luke’s Hospitals, this was associated with a 36% increase in discharges from the ED, a 48% reduction in ‘unnecessary admissions’, and a 48-minute shorter stay in the ED. The KC QVIC is helping sites customize the intervention, implement the pathway, educate team members on its use, trouble-shoot challenges in its integration into care, and help elevate its safety and impact. 

Managed Services Network (MSN): The Mid-America Regional Council (MARC) has built a program to engage and coordinate community based organizations (CBOs) in providing a coordinated network of services to address the social determinants of health such as food insecurity, transportation needs, medical access, etc. The KC QVIC is helping develop a process of identifying patients likely to benefit from MSN services, implement the screening process, develop an efficient pathway for MSN referral, and evaluate the impact of intervention on care. 

Coordination with Payer-led Disease Management Programs: Most commercial payers have disease management programs to help support their members. The KC QVIC is working to help develop an inventory and referral path to help coordinate access to these programs.