by Sachin Jain, MD

In the fall of 2009, Sanjay Doddamani, MD, FACC, was growing weary of re-admitting the same set of “frequent fliers” to his care at Nassau University Medical Center in Long Island, New York. The soft-spoken heart failure (HF) specialist’s practice resembled that of many cardiologists—split evenly between new patients and those who kept returning to the emergency department (ED). The same patients, problems, and treatment course.

“I was getting tired of pushing boulders uphill,” Dr. Doddamani told me. The typical patient in question might come to the hospital several times a month and 20-30 times throughout a year. “I kept telling myself there had to be a better way.”

Dr. Doddamani’s resolve led him to organize a new (HF) clinic for his patients at Nassau, a gritty community hospital on the Queens-Long Island border. Partnering with experienced cardiac nurses led by long-time HF nurse practitioner Deborah Ahern, the team keeps close tabs on patients and works collaboratively to titrate their medications. When patients require care, the nurses are aware of it well before the need for a hospitalization and bring them to a makeshift office-based IV diuretic infusion center.

Dr. Doddamani’s work has shifted focus from the rote mechanics of readmission to satisfyingly keeping patients out of trouble. With a protocol that Dr. Doddamani and his team continue to refine, patients are aggressively managed in the clinic setting with no limits. “The hospital is there if we need it—but so many times it’s unnecessary.”

I interviewed Dr. Doddamani to better understand his model and help glean lessons for others interested in pursuing clinical innovation in HF management.

What was your motivation for pursuing innovation in (HF) management?

Our primary motivation came from recognizing that the current system was not working for patients or for us. The revolving door of the vicious (HF) cycle is incredibly frustrating to patients, their families, and their caregivers.

Through a patient’s eyes, we reassessed every roadblock to care from arrival in the ED through the continuum of inpatient and post-discharge phases, asking ourselves where we go wrong. What can we do better? We established a committed team to take ownership, realizing there is tremendous room for improvement in the current model in four key areas.

And those are?

The first was to address economics in a tangible, beneficial way, which was to reduce inpatient length of stay (LOS) as a measure of quality. Each avoidable inpatient day raises the risk of hospital-acquired infections, pressure ulcers, and overall debility. Cutting one day off LOS equals about a $1,200 cost reduction and possibly more if you account for costs related to infections or ulcers.

The second measure: reduce in-hospital and 30-day mortality. Although nationally HF mortality exceeds many cancers combined, higher inpatient mortality reflects poor quality and access to care and a lack of understanding and resources for end-of-life care (EOL).

The third measure is patient affinity as expressed by increased ambulatory visits. We felt that if we provide great care, why would patients go elsewhere? Maintaining close follow-up has been an important strategy for quality, improvement in care, increased productivity, and for revenue and affinity to our program.

The fourth measure—reduce 30-day readmissions (30DR)—is probably the toughest one to achieve. We have had some success here but before we can significantly cut readmissions, health care needs to undergo a transformational shift in understanding the complexity surrounding readmissions needs. Post-discharge phone calls or remote monitoring are inadequate unless you can intervene and modify therapy.

Having an outpatient HF center to administer IV diuretics has certainly reduced 30DR in some patients but has zero impact on patients with the highest readmission risk, those discharged to nursing homes (NH). Unless we go into the home, replace patient food with healthier options, provide IV diuretics in the NH, divert patients from the ED to observation units, have NH palliative care, and transform EOL, we can only make a dent not a shift.

Tell us more about your practice setting and the community you serve.

We are a public benefit (safety net) hospital that serves three distinct populations. Residents from the five towns we serve in Long Island and Eastern Queens comprise the largest group. Many are elderly and often lack the social and family support that would have helped with many post-discharge care needs including transport. We also serve patients from the area NHs whose 911 calls bring them to our ED.

Finally, we see many indigent patients from the community, including some ethnic minority immigrant populations, unemployed patients with no health insurance, and patients with histories of substance dependence and psychiatric illness. And for us to grow and have the resources we need to deliver high quality care, it has been important to balance the practice with all the patients we encounter.

Many patients lack a primary care physician (PCP) and arrive in the ED either in advanced stages of disease or with minor problems that could have been treated in an outpatient setting. Part of our program focuses on plugging in every patient with a PCP.

Please explain how the model works, comparing the way things were done before to how they are done now. Walk us through a patient who gets care in your system?

Our strategy was to look for ways to improve the care of HF patients, to reduce their LOS and decrease risks associated with hospital admission, to discharge them safely back into their homes to reduce avoidable NH admissions, and to reduce the likelihood of readmission. Readmissions can happen for subsequent exacerbation of HF or for unrelated conditions; our theory was that reducing exacerbations was best accomplished by providing aggressive outpatient follow-up to support all of the improvements I just mentioned.

Additionally, we have increased the scope of weekend services including echocardiography and clinical services, such as weekend homecare enrollment. In the past, if an outpatient was decompensated, the only recourse was to send them to the ED, prompting a response of treat and admit. We now provide intravenous diuretics to outpatients in our HF center, using the opportunity to ascertain the reason for decompensation like dietary indiscretion or disease progression. We provide education, contact the PCP or have one assigned if there is none, and assess patient disability to access resources including health insurance. Many uninsured patients use the ED as their doctor’s office and this is an expensive model of care.

At the start, we evaluated our entire process to address roadblocks the patient encounters; from improving the diagnostic algorithm during ED entry to standardizing the admission order set to better patient identification to conducting multidisciplinary rounds to address all elements of patient care.

In addition to creating the dedicated nursing team, we revamped our entire discharge process to include standardized HF patient education to teach them self-management tools so they understand what symptoms mean in regard to making an appointment with a doctor or visiting the ED.

We discharge more patients home with professional homecare support and schedule aggressive follow-up. We went from targeting our patients primarily with expensive, reactive, unplanned care to more effective, anticipatory care, in a sense moving the fight for their health from the hospital to their homes, a much safer battlefield for the patients.

Heart failure has a high mortality. How do you deal with end-of-life care in your model?

Yes, HF carries a very high mortality, but it is also true that most Americans do not want to die at home and most want to fight to live.

At the same time, hospitals provide little by way of the right surroundings for EOL. Current hospice care is not well understood and carries inherent stigma but has scope to expand and innovate. For instance, patients do not want to stop their dialysis at EOL but hospice does not currently accept dialysis patients. Physicians are caught in the middle. So what we do is to continually engage the patient, readdress code status regularly, and even show up to the ED when the patient is at a terminal stage to triage the care appropriately to either hospice or critical care.

Expanding resources for EOL care and having palliative care resources to be made available at every nursing home will, in my opinion, reduce the number of unnecessary transfers from nursing homes for EOL.

What are the economics of the transition in your model?

By reducing avoidable LOS it’s easy to see how money saved adds up. Our largest investment was in hiring a nurse practitioner and having our procedural nurses reorganize to have dedicated roles in quality nursing time to make intervention phone calls, check labs, and take ownership of patients. The resulting program has been able to identify more patients, perform more necessary echocardiograms, and ensure 100% core measure compliance. With this model, money directed to patient care is invested in making the patients healthier and with more time spent at home than in the hospital.

Sachin H. Jain, MD, MBA, is a physician at Brigham
and Women’s Hospital and Harvard Medical School and
Senior Institute Associate at Harvard Business School’s
Institute for Strategy and Competitiveness. He was previously
a key official in the Obama Administration, where
he helped launch the Center for Medicare and Medicaid
Innovation and the HITECH Act’s Meaningful Use provisions.
He is a leading national authority on healthcare
delivery reform.

Keywords: Follow-Up Studies, Nurse Practitioners, Patient Discharge, Substance-Related Disorders, Triazines, Triage, Renal Dialysis, Outpatients, American Recovery and Reinvestment Act, Pressure Ulcer, Medicare, United States, Sulfonamides, Disease Progression, Echocardiography, Neoplasms, Nursing Homes, Hospice Care, Physicians, Primary Care, Medicaid, Diuretics, Critical Care, Caregivers, Palliative Care, Ulcer, Medically Uninsured, Heart Failure, Terminal Care, Emigrants and Immigrants, Hospitalization

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