Home-based care for heart failure: Cleveland Clinic’s “Heart Care at Home” transitional care program
ABSTRACTWith length of hospital stay for heart failure patients steadily decreasing, the home has become an increasingly important venue of care. Contemporary research suggests that postacute, home-based care of patients with chronic heart failure may yield outcomes similar to those of clinic-based outpatient care. However, the transition to home-based care is associated with a number of risks. Indeed, these patients often experience a downward cycle of repeat hospitalization and worsening functional capacity. In 2010, a group at Cleveland Clinic launched the “Heart Care at Home” program in order to minimize the risks that patients experience both when being transitioned to home and when being cared for at home. This program joins a handful of transitional care programs that have been discussed in the medical literature.
The home is the most important context of care for individuals with chronic heart failure and yet it is the least accessible to caregivers. Patients often struggle to manage a complex regimen of medications, follow an unfamiliar diet, monitor weight and vital signs, and work to coordinate care among various providers who, in some cases, fail to communicate effectively. Heart failure patients do all this while making difficult decisions about their livelihoods, social condition, and future direction. With progression of the disease and comorbidity, these patients often experience a downward cycle of repeat hospitalization and worsening functional capacity (Figure 1). Each subsequent transition from acute care to home becomes incrementally more difficult to manage.
According to the latest American College of Cardiology/American Heart Association Guidelines for the Diagnosis and Management of Heart Failure in Adults, appropriate care for patients with heart failure should include:
- Intensive patient education
- Encouragement of patients to be more aggressive participants in their care
- Close monitoring of patients through telephone follow-up or home nursing
- Careful review of medications to improve adherence to evidence-based guidelines
- Multidisciplinary care with nurse case management directed by a physician1
Beyond these general suggestions, recommendations about specific approaches and models of care in the home are lacking.
Contemporary research suggests that postacute, home-based care of heart failure patients may yield outcomes similar to those of clinic-based outpatient care. Results of the Which Heart Failure Intervention is Most Cost-Effective & Consumer-Friendly in Reducing Hospital Care (WHICH?) trial support this hypothesis. This multicenter, randomized clinical trial (n = 280) compared home- with clinic-based multidisciplinary management for postacute heart failure patients.2 Investigators compared outcomes in patients managed at a heart failure clinic with those managed at home. They found that postdischarge home visits by heart failure nurses did not significantly alter the primary composite end point of death or unplanned rehospitalization from any cause over 18 months (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.73–1.30, P = .8621). The rate of unplanned and total hospitalization was also similar in the two groups. However, the average length of hospital stay was significantly lower in the home care group (4 days) than in the clinic-based group (6 days); P = .004. A cost-effectiveness analysis is planned but has not yet been presented.
HEART CARE AT HOME
At Cleveland Clinic, our group of physicians (geriatrics and cardiology), nurses, nurse practitioners, and hospital administrators founded a primarily home-based postacute transitional care program in 2010 called “Heart Care at Home.” The design of our program was influenced by Coleman et al’s care transitions interventions program,3 Naylor et al’s transitional care intervention,4 and the contemporary remote monitoring literature.5 The program focuses primarily on older adults hospitalized for heart failure who are transitioning from hospital to home. In our model:
- Inpatient care advocates identify candidates during the index inpatient stay, introduce a model of care, and begin a coaching intervention.
- After discharge, home liaisons visit the patient at home, continue coaching intervention, and teach the patient to use the newly installed remote monitoring equipment.
- For 30 to 40 days after discharge, a team of telehealth nurses monitors the patient, makes contact with him or her weekly in order to reinforce coaching intervention, coordinates care, and tracks outcomes.
- Nurse practitioners experienced both in home care and heart failure provide clinical oversight and leadership and visit the highest-acuity patients at home.
To date, the program has provided care in more than 2,100 patient encounters, with approximately 50 to 80 patients actively enrolled at any time. We identified potential program candidates using a digital list tool embedded in Cleveland Clinic’s electronic medical record (EMR) system. This tool was developed by our team together with an internal business intelligence team. We have been approximately 65% successful in identifying eligible inpatients. Patients enrolled in our transitional care program tend to be older, have longer hospital stays, and have more comorbidities than other older adults hospitalized at Cleveland Clinic for similar reasons.
Following index hospital discharge, our home liaisons have been able to make an initial home visit after a median of 2 days (25th to 75th percentile: 1 to 3 days). Patients thought to be at higher risk for hospital readmissions have been seen at home by our nurse practitioners within the first week of discharge. The most common challenge that our at-home team members have faced relates to patients’ medications (for example, unfilled prescriptions and errors in utilization). On many occasions our at-home team has succeeded in transitioning patients not benefiting from care at home to nonhospital venues (skilled nursing facilities, chronic care facilities, inpatient hospice) or to higher levels of at-home care (at-home physician visits, home-care nursing and therapy, at-home hospice).
To date, patients have been enrolled in our program for a median of 30 days (25th to 75th percentile: 20 to 35 days). We have observed an increased level of patient satisfaction. Among heart failure patients enrolled in our program for the first time, we have observed a lower readmission rate compared with publicly reported Cleveland Clinic rates (24.5% vs 28.2%). However, there are several ongoing challenges in the care of heart failure patients in the home environment. These relate to longitudinal care across venues, cross training of providers, and home monitoring.
