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Family & Community Medicine Translates RAP Tier III Funding into Impact


In the U.S., the 30-day hospital readmission rate for heart failure is 27-43%, higher than any other medical or surgical condition. Hospital readmissions are associated with psychological stress, impaired functional status, risk of infection, and mortality. Financial implications can also be substantial; the cost of hospital readmission for heart failure patients exceeds $30 billion annually. As such, the Centers for Medicare & Medicaid Services (CMS) initiated the Hospital Readmissions Reduction Program (HRRP) in 2012 and the Skilled Nursing Facility Value Based Purchasing Program in 2018, assigning a financial penalty to facilities that fail to reach targets for reduced hospital readmission.

Multiple interventions have shown promise in reducing hospital readmissions for heart failure patients discharged to their homes. However, despite the high prevalence of heart failure in the skilled nursing facility (SNF) setting, few interventions focus specifically on reducing readmissions among SNF patients. Dr. Anthony Stavola (Family & Community Medicine, Medical Director for Friendship South Health & Rehabilitation) teamed with Friendship administrators and staff and Accountable Care Strategy colleagues to design and implement a sequential, multi-modal heart failure management program (HFMP) aimed at reducing hospital readmissions for Friendship patients with heart failure throughout 2021.  

Dr. Stavola teamed with Dr. John Epling (Vice Chair for Research and Population Health, Family & Community Medicine) and Dr. Michelle Rockwell (Senior Research Associate, Family & Community Medicine) to perform a retrospective evaluation of the HFMP using the RE-AIM (reach, effectiveness, implementation, adoption, maintenance) framework. A RAP-17 Tier III award ($2500) funded a part-time Research Assistant (Emily Cox, Nutrition Services) to facilitate data collection and statistical support, provided by Dr. Tonja Locklear (Health Analytics).

Highlights of the evaluation include:

·         Of the 42 enrolled patients, two (4.8%) were readmitted to the hospital within 30 days of discharge and four (9.5%) were readmitted within 30 days of SNF discharge compared with historical (2020) rates of 16.7% and 22.2%, respectively.

·         The observed decrease in readmissions was associated with a potential savings of $132,418 to $176,573 in hospital costs, in addition to reduced financial penalties from CMS.

·         Implementation facilitators and barriers were identified for future iterations of the HFMP.

·         Results may inform a randomized clinical trial to further test the HFMP in multiple SNFs.

Findings will be published in an upcoming issue of Gerontology and Geriatric Medicine

[authors: Michelle Rockwell, PhD, RD, Emily Cox, MPH, MS, RD, Tonja Locklear, PhD, Brandy Hodges, LPN (Friendship), Stacey Mulkey, RN, BSN (Friendship), Brandon Evans, RN, BSN (Friendship), John Epling, MD, MSEd, Anthony Stavola, MD).