CHF Care Project - Quality Insights-QIN


CHF Care Project - Quality Insights-QIN
CHF Care Project
Improving Quality of Life for Chronic Heart Failure
Patients through Advance Care Planning
Together We Can Improve Health
for People with Medicare
Timely palliative and hospice care has been proven to improve the quality of
patient care, symptom management and satisfaction, while decreasing healthcare
expenditures for patients experiencing serious disease. Yet, these services remain
under-used across the nation. Heart failure (HF) is the number one principal
discharge diagnosis in the Medicare population nationwide. People with
Medicare who have HF have frequent emergency room visits and hospitalizations.
Evidence demonstrates the importance of palliative and hospice care in improving
quality of life and reducing inpatient and emergency room use in patients with HF
near the end of their life.
Join the Journey
We will convene a learning and action network (LAN) through the recruitment of
participants from the following categories: hospitals within our established care
transition communities, patients/family members, targeted primary care and
cardiology clinicians, and partners and stakeholders. The LAN will provide
education, share best practices, and develop evidence-based interventions to
increase appropriate beneficiary referrals to palliative and hospice care. LAN
interventions, based on needs identified through community root cause analysis,
will include:
1. Developing palliative care teams representing multiple health care settings
that serve patients with HF in advanced disease stages as well as their
families. These teams will help patients manage symptoms, coordinate care
across settings, clarify communication, and carry out informed, self-directed
end-of-life care decisions.
2. Educating clinicians to foster high-quality conversations with patients
and families about advance care planning. These conversations will inform
ongoing patient plans of care. With consent, the clinician can connect the
patient with other providers and resources.
3. Improving competence in provision of basic palliative care for providers
caring for patients with advanced serious illness. Competencies include
communication skills, collaboration across multiple care settings, and
symptom management.
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization for Delaware,
Louisiana, New Jersey, Pennsylvania and West Virginia under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number QI-SIP1-022316
Heart failure is the number
one principal discharge
diagnosis in the Medicare
population nationwide.
In 2014, only about half
of people with Medicare
with heart failure received
any hospice care within
180 days of death, and
40% of those received it
only seven days before
According to the National
Hospice and Palliative Care
Organization (2014), one
third of all hospice patients
enroll in the last week of
Late referrals deny
patients the benefits of
good hospice care, which
includes proper
assessments, caring
relationships, and effective
pain and symptom
CHF Care Project continued
Who Will Benefit?
Our target population for this project is Medicare fee-for-service (FFS)
beneficiaries with an established diagnosis of heart failure (HF). These
beneficiaries reside in the communities where we have already been collaborating
with coalitions to improve care transitions. Communities are located in Delaware,
Louisiana and West Virginia. People with Medicare can benefit from palliative
and hospice care as indicated by worsening symptom control, functional status
declines, multiple hospitalizations over a twelve month period and other
manifestations of serious illness.
Project Goal
As a result of provider, patient and family education, as well as patient selfadvocacy, communities in this project will see increased palliative care and
hospice referrals and fewer late referrals for hospice care. As a result of earlier
referrals, we will see a reduction in hospital utilization and an improved quality of
Learn More
To learn more about joining the CHF Care Project, contact a representative in your
state. We hope you will join us in making a real difference in the health of people
with Medicare.
West Virginia:
Carla VanWyck
State Program Director
(800) 642-8686 ext. 4221
[email protected]
Biddy Smith
Network Task Lead
(800) 642-8686 ext. 3252
[email protected]
Jan Lennon State Program Director (877) 987-4687 ext. 7806
[email protected] Sally Jennings
RN Project Coordinator
(877) 987-4687 ext. 110
[email protected]
Chris Gatlin
Quality Improvement Manager
(225) 248-7035
[email protected]
Kym Herrin
Quality Improvement Specialist
(225) 248-7068
[email protected]
Partner with Us
to Take Part in:
FREE Resources,
Best Practices,
Guidelines and
Engagement through Learning and Action
Networks (LANs)
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