presented by Kenneth L. Miller, Rebecca Crouch & Ellen Hillegass
Readmission to the hospital for patients with heart failure is a national concern. It is a problem for hospitals because it comes with a penalty from CMS if the readmission occurs within 30 days of discharge. Patients with heart failure require monitoring beyond the acute care setting, and current evidence supports continued monitoring of these patients beyond the acute care setting. However, transition from the acute care setting to the home (or outpatient setting) is not always smooth, and communication is often lacking.
This course will discuss the problem of readmission and transition of care, as well as how heart failure is treated in the acute care setting and moves to the home setting. The identification of heart failure patients at high risk for readmission will be discussed, along with the medications the patients may be sent home with and best practice for care in the home and outside the hospital.
Dr. Kenneth Miller has been an educator, physical therapist, and consultant for the home health industry for more than 20 years and serves as a guest lecturer, adjunct teaching assistant, and adjunct professor in the DPT program at Touro College in Bay Shore, New York. He has presented at the Combined Sections Meeting of the American Physical Therapy Association (APTA), the Educational and Leadership Conference of the American Council of Academic Physical Therapy and Education Section of the APTA, and the Annual Conference of the National Association for Home Care and Hospice on a variety of topics, including objective testing, professionalism, interdisciplinary team modeling, osteoporosis, differential diagnosis of dizziness, documentation, patient engagement, student program development, and home health regulations. He serves as chair of the Practice Committee of the Home Health Section (HHS) of the APTA. As the chair, he led the development of the "Providing Physical Therapy" section in the third edition of the home handbook, the Home Health Student Program Roadmap & Toolkit, and The Home Health Section Toolbox of Standardized Tests & Measures. He is a member of the editorial boards of the GeriNotes publication and of the Journal of Novel Physiotherapy and Physical Medicine, and is a manuscript reviewer for the Journal of Geriatric Physical Therapy and the Journal of Primary Care. Dr. Miller has authored numerous articles for the Journal of Geriatric Physical Therapy, GeriNotes, and the HHS newsletter, The Quarterly Report.
Dr. Rebecca Crouch has practiced cardiovascular and pulmonary physical therapy in the acute care and outpatient rehabilitation settings, and was a founding member and director of the Duke University pulmonary rehabilitation outpatient program for 30 years. She is now an assistant professor in the Doctor of Physical Therapy program at Campbell University, and her clinical practice is in acute care at Duke. She has written numerous publications and given presentations in the areas of pulmonary rehabilitation, oxygen management for physical therapists, evaluation and exercise for the cardiopulmonary transplant and medical pulmonary populations, and outcomes measurement. Dr. Crouch has been involved in several professional organizations, including the American Physical Therapy Association (Cardiovascular and Pulmonary Section), American Thoracic Society (state and national), and the American Association of Cardiopulmonary Rehabilitation and Prevention. Dr. Crouch is a business partner in PT Cardiopulmonary Educators, a webinar-based educational service, and is CEO of Cardiopulmonary Therapy Resources, a cardiopulmonary consulting business.
Dr. Ellen Hillegass is a physical therapist with APTA board certification in cardiovascular and pulmonary clinical specialty. She currently holds the position of adjunct professor in the departments of physical therapy at Mercer University in Atlanta and Western Carolina University in Cullowhee, NC. Ellen is also the president and CEO of Cardiopulmonary Specialists, a private consulting firm that provides consulting and education on cardiac and pulmonary rehabilitation. Additionally, she is a partner in PT Cardiopulmonary Educators, a web-based education company for entry-level DPT, residency, CCS board preparation, and continuing education. She also presents courses across the country on early mobility. She has been active in the cardiovascular and pulmonary section for many years and is the former Payment and Policy chair for the cardiovascular and pulmonary section. She has represented the cardiovascular and pulmonary issues of physical therapists at the Centers for Medicaid and Medicare Services along with the APTA on several occasions. Dr. Hillegass started a clinical residency through Mercer University in conjunction with Piedmont Hospital and works with the residents in the ICUs on a weekly basis. Her first resident was recently awarded their CCS this past February at the APTA CSM meeting in San Antonio, where two former residents presented their research as well (one on walking IABP and one with a poster on early mobility). Ellen Hillegass is a member of the Board of Directors of the US COPD Coalition, as well as the chair of the COPD Coalition Strategic Planning Committee. She was the chair of the Clinical Practice Guidelines Committee on Venous Thromboembolism for the APTA (published in Physical Therapy journal in Febrary of 2016), and is the past chair of the Oxygen Recommendations Task Force for the APTA. She is a Catherine Worthingham fellow of the American Physical Therapy Association. She is the editor of Essentials in Cardiopulmonary Physical Therapy, an entry-level text with its fourth edition published in June 2016, as well as the author of a clinical notes book entitled PT Clinical Notes (formerly Rehab Notes). Ellen received her entry-level training in physical therapy from the University of Pennsylvania, her Master of Medical Science in Cardiopulmonary Physiology from Emory University, and her doctorate in Exercise Physiology from the University of Georgia. Her dissertation involved muscle morphology in the spinal-cord injured patient.
Heart failure readmissions are a major concern for the U.S. health system. Medicare has now instituted penalties for readmissions within 30 days of hospital discharge. Possible reasons for heart failure readmissions are explored.
Heart failure is defined including systolic versus diastolic (or HFpEF vs. HFrEF) and staging using the New York Heart Classification versus American College of Cardiology is discussed. Various diagnostic procedures including lab values, ejection fraction, and other diagnostics are discussed as well as an overview of treatment options for heart failure.
Certain risk factors are predictors of higher event rates and worsening clinical outcomes which would make patients at risk for readmission. These are discussed, as well as the actual pathophysiology that brings patients back to the hospital. In addition to risk factors, frailty is discussed as a measure of risk for readmission including methods for measurement of frailty.
Starting with a case study, HF decompensation will be presented including the clinical presentation, medical management, pharmacologic treatment, monitoring, and additional interventions that may be considered. The role of physical therapy and the assessment of frailty is presented followed by a discussion of discharge recommendations for the HF patient.
The first week following hospital discharge to home are the most vulnerable time points where readmission is most likely to occur. Effective information exchange between upstream hospital provider and downstream home care providers is critical to reducing vulnerabilities and errors during transitions. Impaired physical functioning, hospital length of stay, medical complexity, comorbidities, and social support are critical areas to address prior to and after the discharge to insure a smooth transition home.
The home is the most unstructured practice setting requiring patient engagement and activation in self-management. Patient adherence to medication regime, diet, and physical activity are keys to improving outcomes such as quality of life and patient safety. Patient education and communication resources for patient self-monitoring of decompensation reduce rehospitalization rates and are explored here.