Frederick S. Ditmars, Jenna D. Reisler, Gabrielle C. Manno, Grayson R. Jackson and John W. Davis, N. Miles Farr
Heart failure (HF) is a leading cause of hospitalization, costing $108 billion globally with $30 billion spent in the US alone . Much of this burden is due to HF’s high rate of readmission, with 30-day Medicare readmission rates of 24%, and 1-year readmission rates exceeding 60% . Furthermore, socio-environmental factors such as unemployment, poor follow-up, and lack of professional support often represent a greater risk for both readmission and survival than medical factors . Therefore, serving these underinsured populations has proven difficult, with many programs failing to reduce readmission below the Medicare rate . Here, we outline a new 60-day model for the treatment of HF in uninsured patients that incorporates an interdisciplinary team composed of healthcare providers, students, and social workers .
The program is housed at the St. Vincent’s Student-Run Free Clinic in Galveston, Texas, which sees 3,500 patients annually across a variety of specialties. It consists of twice-weekly visits, beginning within three days post-discharge, over a 60-day course focused on vitals monitoring, medication adjustment, occupational therapy, and other services like counseling and pharmacist consultation. Initial medical visits are focused on meeting care gaps, confirming the discharge plan of care, and beginning patient assistance program applications for expensive medications shown to reduce mortality in HF (e.g., dapagliflozin). Additional medical and occupational therapy appointments are scheduled based on symptoms, clinician recommendation, and vitals/laboratory monitoring. Smoking cessation and nutrition counseling was provided on an as-needed basis. Case managers met with patients to ensure that they had transportation, safe housing, and a stable food supply. To assess effectiveness of the pilot, we utilized crude proportion testing (?=0.05) and based our comparison on the known, 2021 30-day HF readmission rate at the University of Texas Medical Branch (21.04%).
While still in its initial phase, our program has successfully treated 75 HF patients ranging from NYHA Class II to NYHA Class IV, with a 30-day readmission rate of 9.3% (7/75) and a 90-day readmission rate of 13.3% (10/75). In 12 months of follow-up, only one patient has died. Compared with the UTMB overall readmission rate, this program was significantly efficacious in reducing 30-day readmissions (p=0.014).
This pilot data supports our hypothesis that interdisciplinary disease management clinics are an effective method to prevent unnecessary morbidity and mortality in uninsured patients with HF. Furthermore, it serves as an opportunity for health professions students to learn the importance of social determinants of health in preventing poor health outcomes.
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