Improving heart failure care for older adults: Gaps and strategies to optimize care transitions

The National Heart, Lung, and Blood Institute (NHLBI) sponsored the workshop to convene an interdisciplinary team of healthcare experts to discuss the current challenges that contribute to adverse outcomes when caring for older adults with heart failure (HF), including rehospitalizations (both HF-related and non-HF-related), functional decline, and diminished quality of life, with particular focus on care transitions. Participants comprised physicians, nurses, and pharmacists, including those with research and clinical expertise in cardiology, heart failure, geriatrics, palliative care, health disparities, clinical trials, biostatistics, epidemiology, mobile health technology, and health policy. The workshop was convened via videoconference on September 27-28, 2021 and consisted of two half-day sessions.

The workshop highlighted recent and ongoing clinical research involving a multitude of patient-focused, provider-focused, and system-focused challenges that could be addressed to improve clinical outcomes, including morbidity, quality of life, and mortality in patients with HF. The primary objective was to identify key knowledge gaps and future research opportunities that could be expected to have the greatest impact on quality of life and reducing hospitalizations in older adults with HF.

Recapitulation of major discussion topics

Introduction

Reducing the burden of heart failure (HF) is a priority of the NHLBI. In 2016, NHLBI unveiled its Strategic Vision after engaging nearly 4,500 diverse scientists and stakeholders from across the U.S. and 42 countries around the globe. The unprecedented number of ideas resulted in 4 research goals and 8 objectives, with each objective having critical research questions and challenges that collectively formed the Strategic Vision. Information on the NHLBI Strategic Vision is available at: https://www.nhlbi.nih.gov/about/strategic-vision. NHLBI Strategic Vision Objective 5 (Develop and optimize novel diagnostic and therapeutic strategies to prevent, treat, and cure heart, lung, blood, and sleep [HLBS] diseases) and Objective 6 (Optimize clinical and implementation research to improve health and reduce disease) were addressed by this workshop.

Discussions

After brief opening remarks and charge, the workshop focused on three specific areas to improve HF care transitions:

1. Patient-level opportunities
2. Provider-level opportunities
3. Policy and system-level opportunities

The workshop began with a session that laid the groundwork for future discussions by reviewing the epidemiology and complexity of HF hospitalizations and care transitions from different healthcare professionals’ perspectives. This was followed by a session addressing some of the challenges that contribute to HF rehospitalizations and other adverse outcomes, including successes and failures of previous interventions and actions that may be required to improve outcomes in the future.

Factors contributing to HF rehospitalizations

Readmission within 30 days occurs in almost one in four patients after HF hospitalization and imposes tremendous burden to patients’ quality of life and national healthcare expenditures. Reasons for readmissions are numerous but include HF progression, iatrogenic causes, suboptimal adherence to effective medical therapies and self-care behaviors (symptom monitoring, diet and fluid restrictions, activity and exercise, follow-up appointments, etc.), complex comorbidities, insufficient social support, and provider-related factors such as non-prescription of guideline-directed medication and devices, healthcare delivery inequity, and inadequate follow-up. Older adults are at particular risk due to concomitant physical and/or cognitive decline, multiple comorbidities, frailty, fixed incomes and more complex medication regimens. Social determinants of health also play a central role in higher rehospitalization rates in this population.

Workshop participants discussed the importance of matching patient goals with outcomes. Current HF treatment paradigms do not adequately address frailty and function, which are essential considerations for the development and implementation of effective transitional care models in older, vulnerable patients. While several relatively small studies of transitional care interventions demonstrated efficacy, they have not yet been validated in large multi-center trials. Simple, scalable interventions implemented at early stages of HF, i.e., well before hospitalization occurs, may more effectively change the trajectory of the disease course with downstream benefits in reducing hospitalizations and functional decline while preserving independence and lowering healthcare costs.

Care Transitions

Workshop participants considered care transitions from a broad perspective, starting from the initial diagnosis of HF and continuing through the disease course, including hospitalizations and discharges, post-acute care, and transition to palliative care and hospice at end of life. Many opportunities exist to improve care transitions, including self-care education, lifestyle and behavioral changes, polypharmacy interventions, home care services, technology, post-acute rehabilitation, and palliative care. Participants noted that how and when to implement complex, multi-pronged interventions, e.g., before, during, or after hospitalization, are not well understood. Most discussants agreed that better metrics for evaluating care transitions are needed and that 30-day rehospitalization is a crude measure that fails to capture quality of care or longer-term patient-centered outcomes. Also, incentives are needed to encourage hospitals to extend care services beyond the hospitalization period. Novel algorithms of care developed using machine learning could potentially identify high-risk patients and match each patient with appropriate interventions to improve functional outcomes and even prevent a hospitalization. Components of transitional care that need refinement are optimal provider-patient/caregiver communication and collaboration that includes shared decision making, development of trusting relationships and delivery of optimal services via an individualized care plan.

Opportunities to Improve Care

Patient-Focused

• Discussion addressed a range of opportunities, including rehabilitation programs, self-care education, lifestyle factors, and use of telehealth and mobile technologies. Key themes that emerged were the importance of establishing trust between patient and provider and the need to integrate cultural and social factors into care at the individual patient level. Speakers identified specific ways that various interventions could be utilized to improve transitions and clinical outcomes. Some key gaps that remain are identifying which interventions for improving medication and dietary adherence and physical activity should be tested, how to improve health literacy in high-risk older patients, and how to incorporate social determinants of health into care pathways.

Provider-Focused

• Discussion addressed opportunities at the provider level, including reducing medication prescription complexity and polypharmacy and optimal utilization of post-acute care therapies, home care services, and palliative and hospice care. Discussants identified gaps in our understanding of how best to use services and how to align services with patients’ goals and preferences. There is a need for pragmatic trials that include patients of advanced age with multiple comorbidities and other vulnerabilities to study the effects of specialized services on rehospitalizations, physical function, and quality of life.

System-Focused

• Discussion in this session considered how national and payer policies affect HF care transitions. The Hospital Readmission Reduction Program (HRRP) has been modestly effective in reducing 30-day rehospitalizations at the possible expense of higher mortality. Thus, the best model for reducing HF rehospitalizations is not clear, and it is possible that different models are needed in different environments. Fee-for-service models do not offer necessary incentives for innovation or team-based care; potential policy solutions to payment challenges were considered. It was agreed that social determinants of health are major drivers of rehospitalization, and that addressing modifiable factors at the system level will be essential for optimizing care and outcomes.

Next Steps

The final session allowed all discussants and participants to share their opinions on which of the ideas discussed over the preceding sessions had the greatest potential to improve transitions, reduce hospitalizations, and optimize patient-centered outcomes in older patients with HF. Small breakout groups discussed specific approaches before sharing their consensus with the larger audience. There was general agreement that an overarching gap is the need for implementation science to determine how best to intervene in these patients to improve HF care. Key themes that were discussed included improving communication between providers and patients to better coordinate care transitions, embracing and addressing multi-morbidity and complexity in older HF patients, greater incorporation of patient-reported outcomes into care and payment models, and integrating social determinants of health into care pathways.