Over the last two months we have been traveling around the country, interviewing stakeholders, and observing the care delivery process across Delaware. Ten key challenges in Heart Failure care delivery emerged from the incredible amount of information we amassed.
Check out the ten challenges below and don’t hesitate to ask us questions in the comment section or tweet at us directly: @health4america.
1. Treatment plans are difficult to adhere to
The treatment of heart failure includes complex medication regimens and difficult lifestyle guidelines that create a substantial burden for patients and often result in treatment non-adherence. Contributing factors include financial constraints, misunderstanding of the disease, limited access to a pharmacy or to transportation, and mistrust of the healthcare system. The average heart failure patient may be prescribed 10-12 medications at once, and up to 40-60% of these medications are not taken as written. (1)
Lifestyle recommendations such as limiting daily sodium, liquid, and alcohol intake, stopping tobacco use, and daily monitoring of weight require constant vigilance in tracking and awareness, which is challenging for most patients. These trends are estimated to contribute to one-third of heart failure hospitalizations. (2)
2. Lack of care coordination leads to inefficient care delivery
As heart failure patients move through disease stages or deal with comorbidities, they interact with a wide range of providers. The current system does not adequately support communication between primary care providers, cardiologists, other specialists, pharmacists, and care team members. Vital information can be lost during care transitions and points of discharge. This discontinuity of care may lead to redundant or overlapping efforts, increased risk of medical error and adverse events, and treatment non-adherence.
3. Health education is a significant barrier to patient health
Patients are often overwhelmed with new information upon diagnosis, regardless of their level of medical knowledge. Furthermore, patients are also managing the emotional and mental burdens associated with a new diagnosis, including fear, anxiety, depression, and/or guilt. Providers face challenges with patient education for a variety of reasons, from serious time constraints to inadequate training in educating vulnerable populations with low health literacy. The net effect is that many patients do not have a strong understanding of their disease, how to manage it alongside other priorities, or how to make informed decisions about treatment.
4. Hospitals must balance readmission penalties and revenue
Heart failure is a leading cause of readmission to the hospital within 30 days of discharge for which hospitals face substantial penalties under the Hospital Readmissions Reduction Program established by the Affordable Care Act. To avoid these penalties, hospitals have made changes throughout the entire continuum of care ranging from protocols for discharge to increased funding for preventative and outpatient services. However, once readmission rates fall below the penalty threshold, further reductions represent lost revenue. Similarly, reductions in patients readmitted more than 30 days after discharge also represent lost revenue. Administrators must strike a balance between funding interventions that reduce readmissions and maintaining revenue streams. This makes it challenging for hospitals to invest fully in interventions that improve heart failure outcomes.
5. Caregivers are underutilized in disease management
Both providers and patient advocates view caregivers as an underutilized resource. There are limited opportunities in the current system to engage caregivers. Device and remote monitoring companies, which primarily focus on patient self-management of heart failure, have begun to address this challenge. Newer products allow for integration of caregivers, empowering them to facilitate treatment adherence and potentially improve patient outcomes. While acknowledging the curative potential of caregiver support, providers and patients alike consistently emphasize burdens placed on caregivers, the risk of burnout, and the need for strong caregiver support networks.
6. Data management is a challenge to remote monitoring
Throughout a workday, providers receive many data points on their patients. With the growth of the remote monitoring industry, this data flow is expected to increase, making it challenging to prioritize more urgent notifications, ensure reliability of data, manage reimbursement, and limit liability for resulting treatment. While these issues are being resolved, remote monitoring companies will do well to identify opportunities for swift and targeted intervention while ensuring robust data management, validation, and prioritization.
7. Mental health is not integrated into chronic disease management
Heart failure patients frequently suffer from mental health conditions that adversely affect outcomes. For example, rates of depression in heart failure are about 40% (3) and these patients have higher readmission rates, higher costs, lower quality of life and higher mortality. (4) (5) (6) Efforts to increase awareness are beginning to take effect with greater recognition of mental health in chronic disease. In addition, recent health reform extends mental health parity to millions more Americans, providing greater coverage of mental health services. Some hospitals have begun to include behavioral and mental health professionals into care teams; such programs are likely to become more common over time.
8. Palliative care makes for an unpalatable discussion
Many patients and families demonstrate reluctance to discuss palliative care. This reluctance is derived from two points: firstly, patients and families do not adequately understand palliative care due to insufficient or inaccurate information. Providers face time constraints to approach the issue in a sensitive manner, and many are not always trained to discuss this topic. Furthermore, the average physician substantially overestimates the predicted lifespan of end-stage patients, (7) while patients may misunderstand treatment options as solutions resulting in false hope.
Secondly, patients and their families often associate palliative care with the concept of giving up or “failure”. The natural alternative to “failure” is to employ all measures available to delay time of death. Accordingly, it is challenging for many patients and families to view discussions around the patient’s values and preferences for palliative and end-of-life care as empowering.
9. Health care tends to be reactive
The current system is designed to react post-event. Insurers continue to reimburse based on volume and quantity of procedures, patients wait to alert providers of their declining condition until time of severe illness, and the healthcare system itself is organized around treatment rather than prevention. Episodic emergent visits are not a sustainable solution for heart failure patients and create a significant financial burden for health systems. Recent health reform aims to reorient the system towards proactive care through coverage for preventative screenings, education, and chronic disease management. Exponential growth in the health and wellness industry indicates that a shift is underway towards prevention and management that is increasingly centered around the home.
10. Care must account for social determinants of health
Social determinants of health are strong predictors of outcome and often dictate a heart failure patient’s ability to navigate the healthcare system. Care disparities have been linked to many differences such as: socioeconomic status, access to education, financial stability, access to transportation, availability of community-based support and resources, housing and neighborhood conditions, and literacy. The current health system is heavily hospital focused and not designed to manage these factors, many of which often have deep roots in the community.
As you can tell no shortage of opportunity areas! Questions? Ask us below.
Bosworth, H.B. Improving Patient Treatment Adherence: A Clinician’s Guide. Bosworth, H.B. (Ed). New York, NY: Springer. 2010
McDonnell, P.J. and Jacobs, M.R., Hospital admissions resulting from preventable adverse drug reactions.Ann Pharmacother. 2002;36(9):1331-6.
Silver, M.A. Depression and heart failure: An overview of what we know and don’t know. Clev Clin J Med.2010;77(3):7-11.
Gottlieb, S.S., Khatta, M, Friedmann E. et al. The influence of age, gender, and race on the prevalence of depression in heart failure patients. J Am Coll Cardiol.2004;43:1542–1549.
Macchia, A., Monte, S., and Pellegrini, F. et al. Depression worsens outcomes in elderly patients with heart failure: an analysis of 48,117 patients in a community setting.Eur J Heart Fail. 2008;10:714–721.
Rozzini, R., Sabatini, T., and Frisoni, G.B. et al. Depression and major outcomes in older patients with heart failure. Arch Intern Med. 2002;162:362–364.
Christakis, N.A., and Lamont, E.B. Extent and determinants of error in physicians' prognoses in terminally ill patients prospective cohort study. West J Med. 2000;172(5): 310–313.