Hospital's experience with heart-failure bundles could be blueprint for others

Keith Schmitt had a hard time accepting that he'd have to change his diet and fast-paced lifestyle after he was hospitalized for congestive heart failure in December 2016. But nurses and physicians at Southwest General Health Center in Middleburg Heights, Ohio, stayed on his case.

He went home with a monitor and scale for weighing himself every morning. If he reported he had a difficult night sleeping or the scale showed his weight rose, a telehealth nurse would call him immediately and ask him what he ate the day before. He also started cardiac rehabilitation right after discharge.

"They kept me focused on what I was supposed to be doing and got me mentally accustomed to my condition," said Schmitt, 62, a field supervisor for a plumbing contractor, who hasn't had another hospitalization or emergency department visit since.

This type of rapid follow-up work with patients, including telehealth monitoring, cardiac rehab and outpatient clinic visits, has been key in enabling Southwest General to succeed where many other hospitals have failed in Medicare's voluntary bundled-payment program for CHF patients.

Since launching its program in 2015, Southwest General has earned nearly $800,000 in savings payments from the CMS, according to consultancy Premier, which has worked with the hospital on the program. Its readmission rate for CHF patients within 90 days has declined by 20%. And patient-satisfaction scores from these patients have soared by 30%.

Given the good results, the independent, 354-bed community hospital in the Cleveland suburbs has applied that same coordinated-care model to all its heart-failure patients, including non-Medicare patients like Schmitt.

The experience also has emboldened Southwest General to consider expanding into Medicare bundles for other clinical conditions and to discuss bundled-payment arrangements with private insurers.

"This isn't done just out of the goodness of our heart," said Jill Barber, the hospital's executive director for payer strategy and population health. "It's an opportunity to gain market share in a very competitive area."

Southwest General's success with CHF patients is unusual.

Many hospitals and physician groups participating in Medicare's voluntary and mandatory bundled-payment program have achieved dramatic success in improving quality and reducing costs for patients receiving total knee and hip replacements. That's the bundle type with the widest participation by far in the voluntary CMS demonstration called Bundled Payment for Care Improvement, or BPCI.

In contrast, most providers have struggled with managing CHF patients, who can be notoriously challenging due to the dire, unstable nature of their condition, multiple comorbidities, and the difficulty of changing bad diet and health habits. CHF is a distant second in popularity within the BPCI program.

Medicare's bundled-payment experiments are seen by many as one of the most promising approaches to improving quality and reducing costs by shifting from fee-for-service to value-based payment. But each condition has a unique set of challenges.

"The bundled-payment program has provided a financial incentive to find areas to improve efficiency and outcomes, and we think it's working," said Chris Garcia, CEO of Remedy Partners, which works with about 700 providers participating in the BPCI program.

The CMS recently announced a new, voluntary five-year bundled-payment demonstration program, called BPCI Advanced. Interested hospitals and physician groups must file applications by March 12.

In the CMS' bundled-payment demonstrations, providers receive a fixed payment for an entire episode of care, covering the initial hospitalization and any care provided for 90 days thereafter. If they hold total costs below a pre-set target, they receive a portion of those savings. If they don't, they lose money.

But for bundled payments to produce major cost and quality improvements across U.S. healthcare, it will have to be effective in managing patients with difficult medical conditions like CHF and chronic obstructive pulmonary disorder. Medicare spent an estimated $21 billion for CHF treatment in 2012 and is projected to spend $53 billion by 2030.

That's why the success of a hospital like Southwest General offers a ray of hope.

After the hospital started its heart-failure bundle in 2015, it took a year of intensive multidisciplinary meetings involving hospitalists, cardiologists, nurses, emergency department personnel, home health and emergency department staff, and leaders from local skilled-nursing facilities to get the program humming, hospital executives said. Three separate groups met regularly to hone processes for pre-hospital and ED care, inpatient care and post-discharge care.

A key factor was the leadership of Dr. Touraj Taghizadeh, a cardiologist who heads the hospital's outpatient heart-failure clinic and who became the program's physician champion.

One of the toughest challenges was convincing independent primary-care physicians and cardiologists to schedule follow-up visits with CHF patients within seven days after hospital discharge. That's critical for quickly addressing patient-care issues such as reconciling medications and improving diet, Taghizadeh said.

"It's a whole new way to practice, and it takes a while," he said. "We physicians don't like change."

Leaders of the effort first attacked the problem of a high 30-day readmission rate, which at one time was hovering around 25%, a little above the median national rate. The hospital hired a nurse practitioner to coordinate the program, established telehealth monitoring, and intensified patient education, management and rehab in its outpatient heart-failure clinic. It also began sending a nurse transition coach to patients' homes within 72 hours of discharge to study their home situation and do basic patient education.

"We go over their meds with them, we teach them how to weigh themselves and avoid salt in their diet, and we tell them what to do if they can't breathe or experience swelling," said Robyn Szeles, a nurse who serves as the hospital's administrator for the cardiovascular service line. "We're there as a support system. We tell them, 'Great job getting weighed every day, and no french fries this week.'?"

"There's no salt on my fries, my meat has just pepper, and I eat unsalted pretzels," lamented Schmitt, the heart-failure patient, who admitted he never had a good diet. "It's not the greatest thing in the world, but it's a pretzel."

By the end of 2017, Southwest General had slashed its 30-day readmission rate to 15.6%. Now the team has set a new goal of 13%.

Team leaders also met with representatives of nearly 20 local skilled-nursing facilities to examine data on utilization and outcomes for heart-failure patients. Length of stay for Southwest General's patients in skilled-nursing facilities started out seven days longer than the national average. Working with the facilities and strengthening use of its own home health agency, Southwest General has chopped 8.5 days from its average skilled-nursing facility length of stay.

"Southwest General is absolutely in the top performer category for heart-failure patients," said Mark Hiller, vice president of bundled-payment services at Premier, which works with 11 hospital systems on CHF bundles. His colleague, Dr. Mike Schweitzer, Premier's principal performance partner, said that by educating patients, their families and their caregivers, and helping them change behaviors, "the program has improved the patients' health for life."

Taghizadeh said it's important to remind physicians about the benefits of the program, though most have been supportive because they see their patients having better outcomes. Attending physicians receive gain-sharing payments from Southwest General as part of the bundled-payment program, though cardiologists and other doctors involved in the care of heart-failure patients do not. Some doctors question what's in it for them financially.

"I tell them we have to keep the big picture in mind, that we are better off keeping our hospital strong and having outsiders know that Southwest is a good place to go for heart care," Taghizadeh said.

In fact, he's convinced that the bundled payment has been critical in pushing his hospital and medical colleagues to work as a team in improving care for heart-failure patients. "It opened our eyes," he said. "It makes everyone realize that when the patient does better, we do better."