Proposed cardiac bundles requires strategic focus on days 31 to 90

In the recently proposed CMS mandatory bundled payment model, hospitals in 98 metropolitan areas will be responsible for costs incurred by their heart attack and bypass surgery patients over a 90-day period. This paradigm shift from 30-day readmission focus to a 90-day at-risk period will require a strategic approach to control the expenses that occur during a period in which costs have been on the rise.

In fact, one research study found that the post-acute cost for care between 30 and 365 days after an initial hospitalization for a heart attack grew 28% between 1999 and 2008.1

As hospitals prepare for the possibility of facing this new challenge, the following tactical options should be considered in effort to minimize the fiscal exposure with this expanded timeline.

Match patient outreach efforts with risk for readmission of the condition. According to one study of 561,926 readmissions of heart attack patients, the daily risk of a first admission to a hospital on day 30, day 60, and day 90 is .4%, .3%, and .2%, respectably.2 The data from the same study suggests that by week 7, heart attack patients may have reached a new stage of their recovery with a lower vulnerability to readmission. Front-loading care coordination outreach during the highest risk period, between hospitalization and day 38 (at which point risk of first readmission has declined 95% from its maximum level) can be one method to efficiently allocating efforts. After this effort, hospitals may find that much less frequent following-ups are required for second-half of the 90-day period.

Apply tactical efforts to reduce the risk of complications or second heart attack – Every year in the United States, 210,000 heart attacks happen in patients who have already had a heart attack3 . Hospital discharge teams, which are often very effective with scheduling initial follow-up appointments, may also be able schedule future check-ups, and reminders, with the patient's heart specialist. This effort can have tremendous impact as the American Heart Association states that heart attack survivors who don't have a timely follow-up with their doctor may be up to 10 times more likely to be rehospitalized.4 If this level of outreach is not an option, making stronger efforts to help the patient identify and engage their social support can also be effective due to the fact that patients with low perceived social support have worse outcomes after a heart attack, including higher likelihood of death or other cardiac events.5

Focus highest risk co-morbidities, starting with diabetes – Stratification of patients by risk is not a new concept, however its worth reviewing the latest research to determine which heart attack patients should receive the most focus. For example, for women who've already suffered a heart attack, diabetes doubles the risk for a second heart attack and increases the risk for heart failure6. This patient subset would likely require additional services as heart failure or shock are some of the most common reason for a 30-day readmission following admission for a heart attack.7 Providing additional transitional care services with the highest risk groups can help to reduce total patient spend with a second heart attack in an efficient manner.

Virginia Feldman, MD is the CEO of Nexus Health Resources www.nexushealthresources.com. Nexus Health Resources offers software and services to skilled nursing facilities, hospitals, and other providers to create a seamless, coordinated transitional care system that provides patient families and caregivers the resources to keep patients healthy at home.

1 Likosky DS, Zhou W, Malenka DJ, Borden WB, Nallamothu BK, Skinner JS. Growth in Medicare Expenditures for Patients With Acute Myocardial Infarction: A Comparison of 1998 Through 1999 and 2008. JAMA internal medicine. 2013;173(22):2055-2061. doi:10.1001/jamainternmed.2013.10789.
2 Dharmarajan, K., A. F. Hsieh, V. T. Kulkarni, Z. Lin, J. S. Ross, L. I. Horwitz, N. Kim, et al. 2015. "Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study." BMJ : British Medical Journal 350 (1): h411. doi:10.1136/bmj.h411. http://dx.doi.org/10.1136/bmj.h411.
3 Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131:e29-322.
4 http://news.heart.org/new-initiative-aims-to-reduce-repeat-heart-attacks/
5 http://news.heart.org/new-initiative-aims-to-reduce-repeat-heart-attacks/
6 http://www.health.harvard.edu/heart-health/gender-matters-heart-disease-risk-in-women
7 Stranges Elizabeth, Barrett Marguerite, Wier Lauren M, Andrews Roxanne M. 2006. "Readmissions for Heart Attack, 2009: Statistical Brief #140"

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