Improving Transitions of Care for Heart Failure Patients: A Novel Payer-Provider Partnership

Disease management (DM) programs are a promising strategy to reduce readmissions after hospitalization for acute heart failure (HF). Although commercial health insurers (payers) often offer DM programs, engaging patients early after discharge can be challenging. To better support the use of payers' DM programs, we developed a referral process for hospital teams to identify and refer patients prior to discharge by educating them about the benefits of DM and to anticipate contact from their insurer, while also alerting the payers to the treatment plans for individual patients.

A pilot of the referral program was tested between a non-profit hospital and 2 regional payers from August 2020 to May 2022. Collaboratively designed by payers, clinicians, and researchers, the process aimed to educate and refer patients being discharged after HF hospitalization. Screening and referral logs tracked referral rates over time, and monthly stakeholder calls were conducted among payers and hospital clinicians to identify barriers and facilitators to iteratively improve the process.

Among 331 patients hospitalized for HF, 76% ( N = 257) were screened. Of those screened, 77.8% ( N = 200) were eligible for referral, and 74.5% ( N = 149) of patients chose to be referred. Of those referred, 17.4% ( N = 26) enrolled in the program. Initially, staff shortages were associated with delayed or incomplete referrals, leading to a centralized process of a single person assuming responsibility for screening and referral, which significantly increased screening rates from 51.9% to 82.4% ( P  < 0.001). Enhanced referral forms containing additional clinical data, alongside payers' electronic health record access, improved enrollment. The lack of a central enrollment registry led to data reconciliation challenges.

This study underscores the potential effectiveness of dedicated staffing to support screening and effectively make referrals to insurers' DM programs. Future initiatives should consider facilitating payers' access to patients' electronic health records, deploying dedicated staff for screening and referral, and creating registries for real-time referral and enrollment tracking.