The HEART (Halt Emergency Admissions and Readmissions Today) Clinical Innovation Program is a novel, innovative project designed to manage chronic unstable heart failure patients in their homes in order to reduce readmissions, improve quality and safety, and lower the cost of care.
HEART consists of three integrated, synergistic components: (1) home-based healthcare to manage the patients at home so they do not require hospitalization, (2) the Mobile Information Utilization System (MOBIUS) which provides an iPad-based information system to improve clinician-patient communication, and (3) if the patient is admitted, coordination of care and an analysis of the causes of the admission that inform home-based healthcare and reduce the patient’s risk of readmission.

National Heart Failure Data Our focus is on heart failure patients. Heart failure is one of the most frequent and difficult-to-deter readmissions. There are over 80,000 new cases of heart failure every year in people 65 years of age and older. Currently, there are 5.3 million patients living with heart failure and there are over one million heart failure admissions every year. Within 5 months of their discharge, 47% of these patients will have been readmitted. The five-year heart failure mortality rate in the years 1996 – 2000 was 48%. The incidence of heart failure is expected to increase by at least 25% by 2030 because: (1) fewer patients are dying of an acute myocardial infarction (they live to experience the effects of left ventricular failure), and (2) there is an unexplained increase in the incidence of nonischemic cardiomyopathy. While approximately 14% of Medicare beneficiaries have heart failure, they account for 43% of Medicare spending. CMS on its Hospital Compare website reported that from July 2008 through June 2011 24.7% of heart failure patients were readmitted within 30 days, with no decline during that time. Each initial heart failure hospitalization costs CMS $9,214 plus the cost of the ED visit (est. $9,714) and each heart failure readmission costs $13,468, plus the cost of the ED visit and physician charges (est. $15,500). Clinical Heart Failure Heart failure is associated with many comorbid conditions and it has numerous clinical effects. The most important effects are: dyspnea and hypoxia, cognitive impairment, reduced functional status, profound fatigue, psychiatric conditions including depression, disordered sleep, peripheral edema, and pain. Further, heart failure usually co-occurs with other conditions, including cardiovascular disease, diabetes, renal insufficiency, anemia, and at least 30% of heart failure patients also have chronic obstructive pulmonary disease. Heart failure’s direct and indirect effects are amplified and augmented by these comorbid conditions. It is very hard to be a heart failure patient.

HEART Home-based Healthcare Program

The clinical problem the HEART Home-based Healthcare initiative addresses is that it is difficult for heart failure patients at high risk for readmission to manage themselves at home or to be managed via episodic clinic visits – thus the necessity of home-based patient management. Clinicians visit heart failure patients that are at high risk for readmission in their homes and manage these patients in their homes. This is a team-based approach; clinicians work collaboratively to optimize the physical and psychological health of the patient.

MOBIUS Innovation Program

Clinician-patient communication is critical to reducing readmissions. We cannot wait until patients to become acutely ill because by then it is too late to stop the readmission. We must communicate with patients every day and manage their illness so that it does not progress to a state that requires a hospital admission. Patients, clinicians, and caregivers will receive iPads that contain applications that assist patients in living a healthy life and managing their disease. The patients will use MOBIUS in their homes so we can assist them throughout the day and night.

MOBIUS (Mobile Information Utilization System) is a novel, innovative iPad-based outpatient clinical information and communication system that patients take home and use in their daily life. MOBIUS reduces readmissions by: (1) interacting with patients and assisting clinicians in managing patients in real time, (2) monitoring patients’ physical and psychological states in real time and reporting these data to the patients’ clinicians, and (3) alerting clinicians in real time when their patients require assistance. The goal is to reduce the readmission rate of high-risk patients through early detection and real time, proximate, effective treatment.

HEART Research Program

• We are creating a “root-cause analysis” program that will allow us to systematically examine the causes for a patient’s readmission. • We are studying the decision making of admitted heart failure patients. We have begun an IRB approved study titled, “Reducing readmissions through shared decision making in an inpatient setting.” It examines how hospitalized heart failure patients make decisions, including the degree of shared decision making and whether their decision-making changes over time during their admission. We expect that this is a novel investigation will lead to patient’s taking more responsibility for their treatment because they feel that they made the decision to take the treatment. • We are designing a study to examine the home environment of readmitted heart failure patients.

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