by Dr. Joanne Lynn
A colleague asks if it makes sense, when engaging in care transitions work, to begin with a disease focus, specifically in congestive heart failure. Innovators do need to start their efforts somewhere, and doing so in areas in which there is a strong will and the perception of a workable plan seems reasonable. Heart failure often meets those criteria, and lots of teams have started there. Even so, it is important not to stay within those boundaries for too long—that’s harder to do, but essential to improving the larger system.
For any diagnostic category, serving a patient in one bed with a better transitions process than the patient in the next bed is (and should be) quite disorienting to the staff. If the better services are perceived as an “add on” for which only some are eligible (as in a grant program or a research project), then the informal message is that the less-good approach is perfectly fine. This makes it hard to generate the outrage that is appropriate in creating intolerance to hopelessly inadequate patterns of care (for all). Thus, one can get away with saying something such as, “This situation is terrible for all, we must change it, we are going to start with CHF and learn enough to make it better for all fairly quickly.” But one really diminishes the odds of success if the message is, “This situation is OK, but could be better, perhaps, and we are going to set out to see if we can make it better for the populations that CMS measures, starting with CHF.”
Also noteworthy is the imprecision in the CHF diagnostic category; especially in older patients, CHF is an indistinct diagnosis that says little more than “not doing well.” When one applies treatments that were developed on cleanly diagnosed (and mostly younger and less frail) patients, one can actually cause great harm. If one takes an elderly person who is labeled as CHF but who really has venous insufficiency and puts that person on a carefully controlled weight monitoring system, you can readily induce dehydration. And all the data on CHF were developed for patients diagnosed with CHF only. The typical complex patient with CHF as part of a complex frailty pattern presents many more challenges.
As improvement teams face the issues of complex diagnoses, or multiple diagnoses, they begin to realize that the CHF patient in one bed is not very different from the person in the next bed who does not have a CHF diagnosis, but has all the same complexities of clinical and social needs (e.g., family support, living arrangements, medication adherence, skin breakdown, risk of falling, and so on).
So, I’d encourage you to bow to the need to get started–but still to try hard to have teams recognize that they need to be more inclusive in their goals and that they need to get on to those goals in a reasonable time. Working with CHF is “a test” and not the whole project. Some, for reasons of leadership commitment, have not done that and have stayed with CHF, or with some other particular diagnosis, such as CHF/Pneu/AMI (chronic heart failure, pneumonia, and acute myocardial infarction, the three that Medicare currently reports on Hospital Compare), and that more narrow approach appears to have hamstrung their progress.
Keywords: congestive heart failure, quality improvement, care transitions, system improvement