This post was authored by Scott Hummel, MD, FACC, from the VA Ann Arbor Healthcare System.

With heart failure (HF) readmissions for Medicare patients in southeast Michigan surpassing the national average of 24.4 percent in 2010, the ACC’s Michigan Chapter decided to take the problem head on by joining together with Michigan’s  Quality Improvement Organization, MPRO, and the Great Detroit Area Health Council to form the  Southeast Michigan “See You in 7” Hospital Collaborative. The goal: increase the number of follow-up appointments scheduled within seven days of discharge by implementing lessons learned from ACC’s Hospital to Home (H2H) early follow-up challenge, “See You in 7.” This post is part of a series on H2H at the local level.

Our HF team at the Ann Arbor Veterans Affairs (VA) Health System now consists of a cardiologist specializing in HF, 2.5 nurse practitioner full-time equivalents, and a cardiology pharmacist. Three years ago, our median time to first appointment for our post-discharge HF patients was over three weeks and our 30-day readmission rates were unacceptable. Like many of the other “See You in 7” participants, we had already started quality improvement efforts prior to the collaborative but learned a lot from the experience. Many of the other hospitals were dealing with multiple cardiology practices, communication challenges, and difficulties with reimbursement for follow-up. The VA, by contrast, is a self-contained system with no reimbursement issues and a longstanding electronic health record (EHR) system that makes inter-provider communication straightforward. However, we see patients from a wide area that includes most of Michigan and northwest Ohio, and many unfortunately have severe socioeconomic difficulties.

Our effort focused on two central issues: 1) primary care and cardiology did not have availability for timely post-discharge appointments, and 2) we were not effectively identifying HF inpatients. We created a post-discharge clinic led by our pharmacist where patients receive education, medication reconciliation, and an exam by a cardiologist or nurse practitioner. Clinic volume improved significantly after we enlisted our internal medicine inpatient team case managers to facilitate referrals and notify the HF team of the admission through the EHR. Our median time to post-discharge follow-up has significantly decreased, and identifying patients early in their stay has helped uncover potential problems with transportation, finances and poor social support. Our post-discharge clinic experience has pointed out gaps in discharge education, which we have started to rectify via a commercially-produced HF video that we provide to all discharged patients. We will soon implement tools for readmission risk stratification into our HF database, and have developed a questionnaire to facilitate management of non-cardiac comorbidities that may affect readmission risk. Using lessons from “See you in 7,” we have established a collaborative within our VA region and aim to develop strategies to reduce readmissions across all VA facilities in our area.

Get additional perspectives from the Southeast Michigan “See You in 7” Hospital Collaborative here.

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