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Geisinger sees big gains for heart-failure-treatment integration


Signs of heart failure.

Geisinger Health System, based in Danville, Pa., has long received attention for its advances in integrated care. Now a piece in NEJM Catalyst says it has used better care integration  to improve medication management and reduce emergency-room visits.

FierceHealthcare reports that Geisinger started to consider every unplanned admission for acute heart failure that required only diuretic therapy for treatment as something to be avoided.  System leaders then developed a “central urgent heart failure clinic, offering onsite review of each patient’s care plan, coordination between nurse navigators and community nurse case managers, and medication management.”

The NEJM Catalyst piece summed up the findings thus:

  1. “High-quality, integrated, multidisciplinary teams can be organized around heart-failure care.

  2. “Heart-failure clinical experts can effectively disseminate, implement, and monitor care plans through community partnerships with nurse case managers.

  3. “A unified approach to assessing heart-failure cases through the electronic medical record, by phone, and during face-to-face encounters helps to integrate the work of multidisciplinary teams.”

Preliminary data indicates that  the new approach saved the system $240,000 in ED visits in 2015, with 28 percent of hospitalized heart-failure patients avoiding emergency care. Meanwhile, monitoring of renal function and potassium rose to 80 percent from 41 percent.

Don’t privatize veterans hospitals


Healthcare journalist Suzanne Gordon writes about why  veterans and other citizens should push back against Republican/Koch Brothers ideas of privatizing veterans hospitals. She says:

“An independent assessment of the VHA conducted by MITRE Corporation, the Rand Corporation, and others and released last year highlighted problems with top-heavy management, cumbersome hiring processes, and delays in access to care in some regions.

“On the whole, however, the assessment also reported that the VHA’s 288,000 employees, including 20,000 physicians, are able to deliver high-quality care to the more than 6 million veterans who receive its services. ‘VA wait times,’ RAND reported, ‘do not seem to be substantially worse than non-VA waits.’ VA patients get care that is often higher quality than that in the private sector — with performance variation ‘lower than that observed in private sector health plans.’ A study published recently in JAMA reported that men with heart failure, heart attacks, or pneumonia were less likely to die if treated at a VHA hospital rather than non-VHA hospital.

“These successes are because the VHA {Veterans Health Administration} has developed into the only nationwide fully integrated health care system in the United States. As such, it provides a model for other systems — one policy makers should be trying to learn from, not dismantle,” Ms. Gordon said.

JAMA study gives good marks to VA hospitals


Card used to obtain VA care.

Despite occasional controversies, veterans’ hospitals compare  favorably with others in treating older men with three common conditions — heart attacks, heart failure and pneumonia, says a study on death rates and readmissions.

The study, in the Journal of the American Medical Association, said that chances of dying or being readmitted within 30 days of treatment for those conditions varied only slightly  between patients hospitalized within the VA system and outside hospitals.

The Associated Press reported that the results contrast with news stories  about quality questions and long waits for care. They suggest that VA hospitals “are still able to deliver high-quality care for some of the sickest most complicated patients,” Ashish Jha, M.D., a Harvard health-policy expert, said in an editorial published with the JAMA study.

At VA hospitals, death rates were marginally lower after a heart attack — 13.5 percent vs 13.7 percent for outside hospitals; and for heart failure — 11.4 percent vs 11.9 percent. They were slightly higher for pneumonia — 12.6 percent vs. 12.2 percent at non-VA hospitals.

Readmission rates ranged from about 17 percent to 25 percent for the three conditions and were highest at VA hospitals, but only by about 1 percentage point or less.

“Both groups are now working on quality in ways they didn’t a decade ago and the levels of good performance are quite comparable” for the conditions studied, said lead author Harlan Krumholz,  M.D., a Yale University cardiologist and researcher.

Tough slog against heart-failure readmissions


Despite a push by the Centers for Medicare & Medicaid Services, private insurers and hospitals themselves against readmissions of people with heart failure, research indicates  that few have achieved  much of a reduction.

Research also shows that safety-net hospitals and others with largely low-income patient populations are at particular risk for heart-failure readmissions; patients from lower-income neighborhoods were nearly 17 percent more likely to be readmitted within six months of discharge.

Yet again, we’re seeing here the social determinants of health in a country with all too few community resources  (compared to other developed nations’) to help low-income people maintain health.

Still, there’s hope in  2013 study that found that six strategies implemented together, rather than individually, could reduce heart-failure readmissions by about 2 percent and save $100 million a year.

The six strategies in the study are:

1. More partnerships between local hospitals.

2. Giving nurses responsibility for medication reconciliation.

3. Arranging for physicians’ follow-up visits to patients before discharge.

4. More hospital partnerships with community doctors and physician groups.

5. Assigning hospital staffers to follow up on post-discharge test results.

6. Setting up a process to send all discharge papers and electronic summaries directly to patients’ primary-care physicians.

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