Montefiore Heart Failure Program Focuses on Fewer, Better Stays


Since 2016, the health system has practiced a heart failure readmission reduction program that's improving patient quality of life.

Katherine DiPalo, PharmD

Katherine DiPalo, PharmD

Cutting down heart failure (HF) readmission could be as simple as identifying the patients at risk for it.

Montefiore Medical Center is entering its fourth year of practice under an institutional registry that identifies former patients with HF upon hospitalization, and transitions them into enrollment with their Hospital Readmissions Reduction Program (HRRP).

In actively tracking and treating a population of about 3000 annual patients, the Montefiore team has already reported a reduced HF readmission rate of more than 20% in recent years.

In an interview with MD Magazine®, Katherine DiPalo, PharmD, the Clinical Program Manager at Montefiore, explained the program has been helping the entire network of care providers involved with treating HF break down silos and transition patients back to everyday life.

“We designed the program within our EMR (electronic medical record) system to create a flag that makes it transparent which patients were admitted for heart failure before,” DiPalo said. “We need to know it’s there. We need a heightened awareness.”

The flagging system allows care providers to create reports that distinguish whether or not the former HF patients have been hospitalized again for the condition. The report carries into outpatient care, where Montefiore’s Accountable Care Organization (ACO) is able to provide its own reports based on treatment plan and patient recovery progression.

Across the health system, the program involves a deep and varied lineup of care providers along its multiple stages: physicians, internists, nurses, care transition managers, and social workers are among the positions collaborating on HF readmission reduction strategies.

DiPalo highlighted a new element added to the program last year: an elected group of ambassadors from Montefiore’s Moses Campus, provided the patient identification and readmission rate data to analyze, discuss, and shape to find the best practices across the dozen facilities using the program. This “sub-steering committee” has generated a new wave of interest in the reduction goals, as well as provided refreshing ideas for improvement.

“There are so many competing things a hospital unit is involved in,” DiPalo said. “We really owe it to staff and our team for keeping HF at the forefront.”

The goal is a particularly pressing one in regions such as Montefiore’s in the Bronx, DiPalo said. The patient population is reportedly living longer, therefore being at greater risk for myocardial infarction and other driving risk factors. Her hope is for the program to transition from reactionary solutions, to public preventive measures.

Still though, preliminary metrics from 2018 indicate he health system reduced HF readmissions by 9% from the year before. Overall, their HF readmission rate is now just under 20%—at Moses, the largest campus, rates have been steady 18%, DiPalo said.

“It’s tough, because it’s always that moving target with the national average,” she said regarding the program’s goal readmission rate. “Our goal is 18% overall. For Moses, we’ve aggressively set a 16% goal.”

The true goal is reducing patient mortality. There’s a large body of literature linking repeated hospitalization due to HF with risk of death. And, of course, there’s an association between reduced hospitalizations and improved quality of life. That’s why one of the biggest roles is that of the patient—education and self-care are critical to the program’s success.

“We want to make sure they preserve their health or recover, and then improve,” DiPalo said.

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