Bill Klaproth (Host): This is a special episode of Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership, recorded live at the AONL 2024 Conference. I'm Bill Klaproth, as we talk about hospital to SNF: Partnership in Expert, Value-Based Heart Failure Care. With me is Jessica Cruz, System Heart Failure Program Manager at Hartford HealthCare. We also have Sean Boyle with us, HVI Central Region Director at Hartford HealthCare. And we have Yan Yan Beach, Advanced Practice Program Manager at Hartford HealthCare. I want to welcome you all to our AONL Podcast booth today. Yan Yan, welcome.

Yan Yan Beach: Thanks, Bill, for the opportunity.

Host: You bet. Jess, welcome.

Jessica Cruz: Thanks, Bill. Nice to be here today.

Host: Thank you for being here. And Sean, welcome.

Sean Boyle: Thank you very much. We're really having a good time at the conference.

Host: It's a great conference, isn't it? I love this conference. A lot of networking, ton of great sessions. It's just awesome. So Sean, let me ask you first, can you tell us about your session and why you wanted to address value-based heart failure care?

Sean Boyle: Yeeah, absolutely. Just to clarify, the SNF, for any of the listeners who don't know what that is, is skilled nursing facilities, so nursing homes is what we were addressing. But really, simply put, is we were looking at reducing 30-day heart failure readmission rates for the patients that were leaving our organization going to the skilled nursing facilities, because it has a dramatic impact financially on organization, but also the care that's being delivered to the patients was not necessarily where it needed to be once they left the hospital.

Host: So, you were trying to make sure that when they leave, they leave. They're not coming back again.

Sean Boyle: That's exactly correct.

Host: So, getting it right the first time, paying attention to that if you will.

Sean Boyle: Correct. Yes.

Host: Okay. So, how did you address this? What did you put in place? What's the program, the tactics, the initiatives? How did you address this?

Sean Boyle: So really, it was convincing our organization that we needed to build this program. We went with the model of having an advanced practice provider, which happens to be Yan Yan, who helped start the program, follow the patients after they left the hospital into the nursing home, and help and consult on the care there, and driving the care that needed to be delivered within the nursing home to prevent them from going back into the hospital.

Host: So, getting buy-in right at the top, really important. Was that kind of one of the first steps?

Sean Boyle: That is exactly correct. That was probably the hardest step, and I relate it back to the Zipline CEO. I don't know if you were able to hear his keynote opening speech where he had to convince the Ministries of Health to invest in his program. It was the same thing. We had to convince our upper leadership to invest, spend money to save money, essentially at the end of the day.

Host: And you mentioned Yan Yan was critical in that. Can you talk about your involvement, Yan Yan?

Yan Yan Beach: Yeah, just basically making the staff accountable and just reinforcing the fundamentals of care. And just my background, my education, and providing them more education and the whys and the hows of what they're doing and just basically empowering them so that they know how to take care of this complex population.

Host: So Sean, what were the nuts and bolts this? How did you address this? "Step one, we're going to do this. Step two, we're going to do this. Step three..." What were steps?

Sean Boyle: So really, it was business plan creation, creating that financial picture of what this was going to look like and getting that buy-in from the organization to spend the money. It was then hiring the advanced practice provider. But then, the other biggest part of it, the next step was really convincing the nursing homes or the skilled nurse facilities that this was a beneficial program to them, not just to us, at the end of the day, to make sure that they were delivering the best care, and we were going to help them provide that, at really, essentially, free of cost. We weren't charging them for us to come in and consult on their patients.

Host: So, convincing them, "Hey, there's an ROI in this for you. This is really important for you."

Sean Boyle: Exactly. Exactly. Correct.

Host: So, Jess, for another organization that wants to do this and follow in your footsteps, where should they start? What's the first critical thing to do? I know Sean kind of outlined some of that, but what's some of the other top line things we need to be aware of before embarking on a mission like this?

Jessica Cruz: Sure. You know, Sean mentioned the business plan, which is really important, but I think even if you can't obtain leadership buy-in, maybe doing a pilot with an APP that you already have in your organization and finding other skilled nursing facilities in the community that are interested in partnering, because we've found that the most successful skilled nursing facilities are those that are interested in our program and not us necessarily seeking them out. So, I think finding partnership that want to make change and increase their quality of care is really important. So again, you know, just piloting something small. One or two SNFs to partner with I think is a good first step.

Host: How do you find a partner? What are the steps to finding that right partner that fits what you're looking for?

Jessica Cruz: Yeah. So, we looked at location near our hospitals. The SNFs that are closest to our hospitals, but also get the highest volume of our patients, the patients that get discharged from the hospital and go to the SNF. So, that was important, because we want to get a high volume so that we can prevent readmission. So really, just reaching out to the leadership and the skilled nursing facility to showcase what we can bring to the table and how we can bring specialized care right to the bedside free of charge. That was a really important piece that there's no cost to this program. Cost on our end to pay for the APP, of course, but the return on investment is key for the community, for the patient, for our organization.

Sean Boyle: I will add too that we had the advantage of having nursing homes that were affiliated or part of our healthcare system, which also helped as a starting point for us. So, if there's other systems out there that are looking to emulate this program, that is certainly a starting point, looking at affiliates of your healthcare system as well.

Host: Yeah, that makes sense. And we've been talking about the benefits to the SNF, if you will. Yan Yan, can you talk about the benefits to the patient, the better outcomes for them that they don't have to have readmission after 30 days. Can you talk about that aspect of it?

Yan Yan Beach: Absolutely. So, assuring that they are following the guideline-directed medical therapy that's been proven and shown to, you know, not only reduce re hospitalization, but certainly reduce mortality, increase the quality of life, and also providing the resources that nursing homes, unfortunately, are not privy to or not aware of. So, we serve as that bridge to that community care that's available to them and certainly, establishing other type of resources as well and also alleviating the financial burdens that, unfortunately, this population does have. So, aligning AHA care too with these facilities.

Host: Yeah. Those are important points to remember, so thank you for that. So, as the program manager overlooking all of this, what are some of the key takeaways from your perspective?

Yan Yan Beach: That persistence is key, and showing them that you are ahead of their team. That you're not just a person that comes in, sees the patient and leaves and you don't turn back, but that you're invested and you're involved. Communication is huge. So, you're constantly talking to them and making sure that they know that their voice and their feedback is just as important in order for these programs to be as successful as they've been.

Host: Yeah, absolutely. And Jess, how about the results so far? I know what the mission is, you're trying to reduce the 30-day heart failure readmission rate. What have your results been so far?

Jessica Cruz: So, this program's been in place for four years. Year after year, we consistently have a lower readmission rate, up to 12% lower some years when you look at compared to our Hartford HealthCare other regions of patients that are leaving the Hartford HealthCare system and going to SNFs that aren't part of this partnership. And even more so, there's a larger gap and more consistent reduction for non-Hartford HealthCare hospitals in the state of Connecticut. So, we've seen really, really good results and outcomes. And our APPs are really making a difference every day. It's a little challenging to figure out how many patients would have been readmitted. But looking at the prediction of the cost savings, and it's about 1. 3 million over that four-year period. So, really, really good outcomes.

Host: That's a lot of money. That's a lot of ROI.

Jessica Cruz: A lot of money.

Host: Good job on that. Sean, anything you learned along the way or anything that surprised you in putting this program together?

Sean Boyle: I think the relationships we built with the nursing homes were invaluable. I wasn't certainly expecting that. I think we got more services out of this program than we expected with other things that they wanted to partner with us in. And then, one other key takeaway was from just being the financial person is that, while this was free of cost, it did put a little more of a cost burden on the nursing home. Nursing homes don't have a lot of profit to play with. So, something we had a really big takeaway on is that the care we were delivering hired the cost of care in the nursing home, but really at the end of the day with the cost avoidance that Jess talked about, really outweighed all of that.

Host: The cost avoidance. Yeah, that's good. Well, I want to thank you all for your time today. This has really been interesting. Thank you again for stopping by our podcast booth here. I'd love to get each of your own thoughts as we wrap up from your point of view. Yan Yan, let me start with you. Anything else you want to add?

Yan Yan Beach: So, these nursing homes have followed a certain culture for so long. And I feel that since we've implemented this program that we're helping these nursing homes evolve and helping this nursing staff especially to use more critical thinking skills and that these complex patients are meeting now the care that they truly need.

Host: Yeah, good point. Well said. And Jess, how about you? Final thoughts?

Jessica Cruz: I just want to share that there's been some unexpected benefits of this program, so it's really strengthened partnerships within our community and has allowed for other programs to partner with SNFs. Endocarditis program is partnering with one of the nursing homes that we do. Our Ventricular Assist Program as well is now partnering with one of the SNFs. So, it really has opened up some doors for other programs as well.

Host: Yeah. So, some additional benefits to doing this too. Yeah, great work. And Sean, how about you? Final thoughts?

Sean Boyle: I would say getting that buy-in, which can sometimes be the hardest part, is finding that right person to get latch onto to help you promote and market this is key to implementing something like this.

Host: Yeah, it takes a team, right? And certainly that top leadership, giving you the blessing, certainly critical in all of it.

Sean Boyle: Absolutely.

Host: Yeah. Well, I want to thank you all for your time today. This has been awesome. Once again, with us is Jessica Cruz, we have Sean Boyle and Yan Yan Beach. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.