012 - Heart Failure Care Coordination Increases Post Discharge 7 and 30 Day Appointment Completion

Introduction: Rising costs have resulted in a wide interest to improve health care system effectiveness and efficiency. Patients with a chronic disease such as heart failure (HF) are forced to navigate complex, inefficient systems. Healthcare providers are tasked to improve outcomes and patient experience while reducing costs. Care coordination (CC) is an increasingly widespread initiative being implemented across health care systems to achieve these goals. Hypothesis: Implementation of a HF specialty care coordinator (SCC) may facilitate care transitions, increase outpatient appointment completion, and reduce all-cause 30 day readmission. Methods: In March 2015, a pilot position for an outpatient HF SCC was created in the Heart and Vascular Institute at the Cleveland Clinic. The SCC is an RN experienced in HF management who follows patients for 30 days post discharge. SCC interventions include: education, face to face visits, weekly phone calls, medication coordination, health coaching to enhance self-care skills, and facilitation of care team communication. Outcomes measured were completion of 7 and 30 day post discharge follow up appointments and 30 day all-cause readmission. CC was provided to patients who were admitted to one of two parallel services which provide inpatient specialty HF care. We compared outcomes between patients who received CC vs patients who did not. Results: Initial data revealed a statistically significant improvement in post discharge 7 and 30 day appointment completion. The 7 day appointment completion rate for non-SCC patients (N = 1717) was 24% vs 73% for SCC patients (N = 277) (P < .00001). The 30 day appointment completion rate for non-SCC patients was 44% vs 67% for SCC patients (P < .00001). There was no significant difference noted in 30 day readmissions between non-SCC patients (17%) and SCC patients (18%) (P = .67). An improvement trend was noted in the readmission rate for patients discharged with home care. The 30 day readmission rate for non-SCC patients (N = 317) was 27% vs 20% for SCC patients (N = 87) (P = .15). Conclusion: Implementation of a HF SCC significantly improved 7 and 30 day appointment completion for recently discharged patients. There was no significant difference in 30 day readmission between the non-CC vs CC patients. Patients discharged with home care who received CC demonstrated a trend toward improvement in readmission. A larger study will be required to determine the true impact of CC on readmission as this current study may be underpowered.