Improving Transition of Care for Acute Myocardial Infarction Patients

From the 2019 HVPAA National Conference

Ms. Heidi McCoy (Michigan Medicine), Ms. Carali Van Otteren (Michigan Medicine), Dr. Adam Stein (Michigan Medicine)

Objective/Purpose

At Michigan Medicine, the average time to post-discharge follow-up for patients with acute plaque rupture events (ST-elevation myocardial infarction (STEMI) or type 1 non ST-elevation myocardial infarction (NSTEMI)) was 29 days in 2017. To comply with Cardiology guidelines, the Cardiovascular Center engaged with Clinical Design & Innovation, division of Quality, to improve lead time to 7-14 days.

Methods/ Approach

To address this gap, multi-disciplinary teams collaborated with Clinical Design & Innovation Project Managers and Industrial Engineers by mapping the current state and defining opportunities for improvement. Four main themes surfaced and subgroup teams were formed. Each subgroup conducted data driven root cause analyses which revealed the following four barriers to timely follow-up:

  1. No formal transition of care process existed.
  2. Inpatient provider teams had no standardized communication and education.
  3. No available clinic appointments within 7-14 days.
  4. Inconsistent patient education

The subgroups implemented interventions that were measured biweekly to evaluate success and ensure sustainment, where applicable.

Results/Findings

Subgroup teams implemented and measured the following countermeasures:

  • Process flows to define transition of care.
  • A resident curriculum included 1) identifying and treating AMI patients; 2) beginning transition of care process; and 3) generating a discharge summary.
  • Standardized Bridge clinic schedules and manual appointment reminder phone calls
  • Patient educational materials affirming the importance of medication adherence and completing follow-up appointments.

After 18-month engagement, the subgroups collectively obtained the goal of follow-up care within 7-14 days post-hospitalization.  STEMI population decreased from 24 to 9.8 days and NSTEMI population from 29 to 14 days, which are decreases of 59% and 52%, respectively.

The program has reached sustainment and the days to follow-up care post-hospitalization continue to decrease.  STEMI population decreased from 9.8 to 5.9 days and NSTEMI population from 14 to 12.5 days, which are overall decreases of 75% and 57% from where we started pre-implementation, respectively.

Conclusion/Practical Implications

      Subgroups reaching true root cause allowed the AMI program to meet the objective of improving the time to follow up for patients. We learned that implementing change in a large teaching institution that balances clinical care, teaching, and research objectives is complex. Monthly rotating resident and attending physicians makes implementing change very challenging. In this environment, effective multidisciplinary communication throughout a patient’s transition of care is pivotal.  One key aspect was involving the patient’s voice in the development of processes. Lastly, we learned that developing sustainment plans with subgroup leads allowed us to measure the successfulness of the implemented changes.

Figures

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPAA on Health Affairs Blog