This document describes a quality improvement project to reduce readmissions among uninsured cardiac patients at a large public hospital on the U.S.-Mexico border. The project implemented a protocol to provide uninsured patients with a 30-day supply of essential medications upon discharge. Retrospective data showed high readmission rates and costs prior to the protocol. After implementing the protocol, zero readmissions occurred during the study period. The protocol demonstrated the value of ensuring uninsured patients can access needed medications to improve outcomes and reduce costly readmissions.

1. Improving Outcomes for Unfunded
Cardiac Patients: A Team Approach
Joe Garcia DNP, RN

2. Importance Of Quality Improvement
• Under Medicare's Inpatient Prospective Payment
System (IPPS), as included in the Affordable Care
Act (ACA), there will be adjustments to payments
made for excessive readmissions in acute care
hospitals during fiscal years beginning on or after
October 1, 2012.
• A readmission is defined as: being admitted at
the same or different hospital within a period
(generally 30 days) for certain applicable
conditions.
Heidenreich et al,(2011)

3. Conditions/Impact
• Myocardial Infarction (MI), Congested Heart
failure (CHF), Pneumonia (PN).
• Between 2010-30, the cost of medical care
for heart disease will rise from $273 billion to
$818 billion.
Heidenreich et al,(2011)

4. Importance
• Largest public hospital located directly on the
U.S./ Mexico border.
• Serves the third poorest county in the nation.
• Per-capita income in the hospital’s primary
service area is just $17,618.00.
• Majority (80%) of El Paso's population is Hispanic
and many are fluent only in Spanish.
• 33.2% of the 800,647 residents are uninsured.
Texas Comptroller(2012)

5. Aim/ Goal
• Implement a low cost high impact discharge
protocol/ model for the
uninsured/underinsured patients that require
essential medications upon discharge.
• Improve patient care quality and minimize
readmissions and their costs; among this
population on a continuous basis.

6. Background
• Ischemic cardiovascular disease (CVD) is the
most common preventable cause of death in
the U.S.
– Creates major health and cost issues with
regard to hospitalizations and readmissions.
– Readmissions stem from non-compliance
with medication therapy.

7. Background
• Following hospitalization for CVD, one-fifth of
Medicare patients are readmitted within 30
days. ( Berenson et al, 2012).
• Readmissions are costly and their impact –
financial and otherwise – is increased by the
fact that readmitted patients have a higher
mortality rate ( Kavey, 2003).

8. Background
• Readmissions and their ever attendant, ever
increasing burdens are often preventable (
Yost et al, 2010)
• Major factor in readmissions is that patients
delay, stop, or never fill their prescriptions
post discharge ( Yost et al, 2010)

9. Significance Of The Problem
• Each year there’s six million hospitalizations due
to heart disease ( AHA, 2007).
• Ten million cases annually of disability for
Americans age 65 years and older (AHA, 2007).
• Approximately 1.2 million Americans suffer heart
attacks each year (CDC,2009).
• Of that number, 700,000 are first-time attacks
and another 500,000 are experiencing recurring
attacks (CDC, 2009).

10. Case Study
• On the 14th week of the study, Cath team
performed an urgent percutaneous coronary
intervention (PCI) on 38 y/o patient with
previous history of myocardial infarction.
• Primary admission was September 12, 2012.
• Information obtained from the electronic
health record (EHR) proved additional injury
to the myocardium.

11. Case Study
• The EHR and images taken during the
procedure revealed that all three major
vessels had in-stent thrombosis.
• Documentation in the EHR stated the
patient had self-reported non-compliance
with previously prescribed medications.

12. Review Of Literature
• “The most common etiology of...
readmissions due to complications of PCI was
in-stent thrombosis” (Yost et al, 2010).
• In-stent thrombosis is the leading adverse
event associated with early discontinuation of
essential medication therapy (Yost et al,
2010).

13. Review Of Literature
• One study found 1 in 6 patients delay filling
their prescriptions after hospital discharge
after having coronary intervention (Ho et al,
2010)
• Premature discontinuation of medication
therapy is the single greatest predictor of
complications post intervention and has a 25
to 40% mortality rate (Ho et al, 2010 ).

14. Quality Assurance Framework
( Avedis Donabedian)
• Provides a tool for measuring quality of care.
• A multidisciplinary approach to process
change.
• Powerful tool for change and measuring
improvement.

15. Ethical Considerations
• Study inclusion criteria required that all
project participants be older than 18 years
with proper documentation of medication
dispensed at discharge.
• Prior to implementation, the project was
assessed by the institution’s IRB officer and
determined to be a quality improvement
project, which did not require IRB review.

16. Method
• Plan, Do, Study, and Act (PDSA) cycles are a means
of doing effective, consistent quality improvement
over multiple discrete phases and iterations (IHI,
2011). 10
• This quality improvement protocol had three
distinct phases:
1. Building the best practice tool using a pilot;
2. Implementing the tool based on pilot data; and
3. Monitoring and utilizing the protocol to actually
increase compliance.

17. Important Factors Of Project
• Partner with pharmaceutical companies to
provide a free 30-day discharge supply of
medications to uninsured and underinsured
patients that have received cardiac treatment.
• Reduce or eliminate medication associated
readmissions.
• Increase the transition and coordination of
care provided.

18. Implementation
• A prospective study was conducted
implementing the proposed medication protocol
that involved the
physician, nurse, pharmaceutical company, social
worker, and pharmacists.
• The study was conducted for an eight-week
period while observing for the outcome of
interest. Findings were compared to those
obtained in the retrospective study.
• All data collected was obtained from the EHR
along with pharmacy dispensing data.

19. Best Practice Tool

20. Best Practice Tool

21. Medications To Date

22. Basic Steps Of The Discharge
Medication Protocol
Step 1. Rational
Start discharge process on admission. Helps identify the financial and pharmaceutical needs of the patient.
Assist the uninsured to enroll into Medicare/ Medicaid.
Step 2.
Interdisciplinary Communication Completing and faxing computerized form within 24 hours of admission.
On approval, pharmacy communicates to the physician and case manager
the need for prescriptions.
Step 3.
Medications Pharmacy delivers 30 day supply of medications on discharge day.
Simplify management plan, acquisition of medications, storage, and
proper administration.

23. Basic Duties Of Discharge Team
Participant Role
Patient financial representative Conducts/completes computerized pharmaceutical form and
delivers to pharmacy.
Pharmacists Conducts medication reconciliation, looks for gaps in
medication that may have lead to hospitalization, and
authorizes the dispensing of essential medications.
Case manager Notifies physician of patient pharmaceutical status and
request prescriptions.
Social worker Assists patient access community services such as
transportation to appointments, coordinates with
behavioral specialists to provide support to patients with
depression, particularly post Myocardial infarction.
Nurse Sets discharge planning in motion. Role includes hospital
discharge planning to include DC teaching.

24. Project Design
• Data was collected from two retrospective
chart reviews:
– May 1, 2011 through July 30, 2011
– May 1, 2012 through July 30, 2012
(Retrospective studies use existing data that has
been recorded for reasons other than
research)

25. Findings Retrospective Review 2011
May 1, 2011 through July 30, 2011
• Cath team performed a total of 40 Urgent/
Emergent PCI’s.
• One patient returned to UMC within a 30 days.
• Charity care
• Length of Stay (LOS) (3) days
• Costs associated with readmission $52,376.14

26. Findings Review 2012
May 1, 2012 through July 30, 2012
• Cath team performed 26 Urgent/ Emergent PCI’s.
• Five patients returned to UMC within a 30 days.
• One Medicare , four self-pay
• Average Length of Stay (LOS) 5 days.
• Total charges for second readmission $298,660.28
Financial Impact Combined
2011 and 2012 = $351,036.42
Or $58,506.07/ patient

27. Prospective Study Findings
November 1, 2012 through January 31, 2013
• Cath team performed 38 Urgent/Emergent PCI’s.
• All discharges had the 30-day supply of essential
medications.
• No readmissions
• Continued through February
• No readmissions

28. Secondary Findings
• 98% of the population qualified for the free
30-day supply of medications.
• HCAHPS scores rose from 87% to 99%.
• Three enrollments

29. Barriers To Implementation
• Resistance to change
• Various interests
• EHR Challenges
• Education

30. Recommendations
• Given the association between
discontinuation of medications and 30-day
readmissions, additional strategies are
needed to identify and understand the
discharge process.
• Quality improvement initiatives must be
undertaken to better educate patients about
their diagnosis and medications.

31. Recommendations
• Evidence-based medication protocols are
necessary for patients who have been
discharged to ensure initial filling of
prescriptions and prevent the delay or stoppage
medications.
• The hospital team must identify and determine
the best approach to increase adherence.
• For patients who cannot afford the essential
therapy due to demographic, educational,
economic, and social-cultural factors, alternative
medication regimens need exploration.

32. Summary
• Adherence to medication is one of the most
interesting and difficult to understand behaviors
demonstrated by patients.
• Adherence is affected by demographic,
educational, economic, and social-cultural
factors.
• Non-adherence to a therapeutic regimen has
shown to result in negative outcomes for
patients and may be more complex in
populations with multiple morbidities that
require multiple drug therapy.

33. Summary
• This project focused on a protocol to provide
unfunded CVD patients necessary
medications upon discharge.
• The use of the protocol clearly demonstrated
the value of providing essential medications
to unfunded patients following PCI.
• During the study period, there were no
readmissions within the 30-days following
discharge.

34. Sustainability
• Teams will have to have standardized
methods of monitoring these outcomes.
• Periodically present findings to staff to show
that goals are being met, or to discern
reasons why they are not being met.
• Make the necessary changes to protocols that
would address these issues.
• Collect monthly statistics on patients that are
both admitted and readmitted for CVD care.

35. Result Distribution
• Abstract submitted for poster presentation to
the Mano Y Corazon 2013 Bi-national
Conference of Multicultural Health Care
Solutions. September 2013, El Paso, Texas.
• Manuscript submitted to the Journal of
Nursing Care Quality on April 11, 2013.

36. Coming Quality Improvement
On March 6, 2013 submitted for grant funding.
•Advocate for the poor and disparate population of
El Paso.
•Engage the El Paso community to improve CVD
awareness through screening, culturally
appropriate bi-lingual education, promote change
in dietary habits, and increase awareness of
warning signs of heart attack and importance of
calling 911.

37. Coming Quality Improvement
• Million Hearts campaign: a National initiative
that was launched by the Department of
Health and Human Services in September
2011 to prevent 1 million heart attacks and
strokes by 2017.

38. Case Study
• Balloon pump for 6-days (CCU bed) $10,800
• 15-20% ejection fraction verified via MUGA
$871.00
• Back to cath-lab. Right coronary artery opened
$23,162.23
• By-pass for remaining two arteries $76,421.40
• Pharmacy $8464.25
• Supplies $9621.00
• Total costs for readmission $129,339.88
Could this have been prevented ?

39. References
• American Heart Association. (2007). Cardiovascular Disease Statistics. Retrieved from http://www.heart.org/
• Berenson, R.A., Paulus, R.A., & Kalman, N.S. (2012). Medicare's readmissions-Reduction program. New England Journal of Medicine, 366, 134-136.
• Centers for Disease Control and Prevention. 2009 Know the Signs and Symptoms of a Heart Attack. Retrieved July, 01 2012 from
www.cdc.gov/dhdsp/data_statistics/fact_sheets/.../fs_heartattack.pdf
• Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., Finkelstein, E. A., Hong, Y., Johnston S.C., Amit, K., Lloyd-
Jones, D.,Nelso, S.A., Graham, N., Orenstein, D.,Wilso,W.F.,& Woo, J. (2011). Forecasting the future of cardiovascular disease in the United States: A
policy statement from the american heart association. Circulation, 123, 933-944.
• Ho, M. P., Thomas, S. T., Thomas, M. M., Powers, D. J., Nikki, C. M., Jackevius, C. E., Go, A. S., & Margolis, K. L., DeFor, T.A. (2010).
Delays in filling clopidogrel prescription after discharge and outcomes after drug-eluting stent implantation. Circulation, 3, 261-266.
• Institute for Healthcare Improvement. (2009). Care Coordination Guidelines. Retrieved from http://www.ihi.org/
• Institute of Medicine. (2000). Care Equity Report. Retrieved from http://www.iom.org/
• Kavey, W. E. R., Daniels, S. R., Lauer, R., Atkins, D. L., Hayman, L., & Taubert, K. (2003).American heart disease guidelines for primary prevention of
athersclerotic cardiovascular disease beginning in childhood. Circulation, 107, 1562-1566.
• Khot, N. U., Johnson, M. L., Geddes, J. B., Ramsey, C. A., & Khot, M. B. (2008). Financial impact of reducing door-to-balloon time in st-elevation
myocardial infarction: A single hospital experience. BMC Cardiovascular Disorders, 9, 32.
• Neushausen, M. B. (2004). Avenis Donabedian: father of quality assurance and poet. Quality Safe Healthcare, 13(6), 472-473.