Jain’s Innovators: Innovating Heart Failure Care: One Health System’s Journey (Part 2)

      by Sachin Jain, MD

In Part 1 of this interview, which ran in the January issue of CardioSource WorldNews, Sanjay Doddamani, MD, chair of cardiology at Nassau University Medical Center, talked with Dr. Jain about some of the ways his clinic is employing innovative approaches in the delivery of care to their HF patients. In this second and final part, Dr. Jain and Dr. Doddamani discuss some of the results Dr. Doddamani’s team has achieved, and also the role of technology in achieving them.

Can you describe the role of teamwork across specialties and clinical disciplines including nurses, physicians, case managers, and others?

Heart failure is the culmination of years of elaborate interactions among genes, health, and lifestyle. Patients with HF need the assistance of physicians for treatment, nurses for care, dietitians for nutritional management, social workers to ensure that they have access to needed resources in order to navigate the pitfalls that can lead to exacerbation or early death. One of our biggest successes was the institution of interdisciplinary rounds in which every aspect of patient care is discussed. Our best efforts at treatment are doomed if we don’t consider whether patients can afford medication, if they have someone to drive them to their next appointment, if they are eating right, and if they are adequately managing their comorbidities. This interdisciplinary team has been vital to our accomplishments.

What have been the tangible results achieved?

From a global cardiology standpoint, our ambulatory presence increased from a baseline of fewer than 1,000 visits in 2008 to more than 5,000 ambulatory visits this past year. This is tangible evidence of having significantly increased patient access to our providers. Compliance with core measures is up.

Mortality has been reduced both in AMI and CHF. There is an overall trend to reduced readmissions. Our length of stay has decreased to about 5 days from a baseline of 6.8 days in 2008. We have seen over 500 patients in our HF center within the past year. Given that we are able to provide IV diuretics to outpatients, there is greater confidence on the part of the discharging physician to let the patient go home a day earlier and be seen and get an injectable diuretic the next day if needed. Since the inception of our twin program in cardiac electrophysiology, we have done about 170 device implants—our hospital previously did not offer implantable defibrillators on site, and there were fewer than 20 transfers for ICD therapy in 2008.

A great deal of time is spent educating patients and their caregivers about chronic disease management from etiology, symptoms, medications (type, purpose, dosing, and side effects) and self-management tools. This process has increased overall health literacy in this population, which in my opinion has helped to reduce readmissions in patients who previously relied on the ED for urgent care. Over time, we have found patients taking control of their disease through self-help and modifying their behaviors with diet, controlling chemical and other substance dependences, and partnering in their care. We feel this one of the biggest successes of our program.

What has been the role of information technology in your model?

We started off as a bare-bones project with limited IT resources. I am confident that this will change very soon. So far, the hospital’s information systems support team has enabled us to greatly improve patient identification and cohort our group electronically by one of three parameters: pro-BNP, IV diuretic use, and ejection fraction. There is no doubt that patient identification has improved with the use of these tools.

We have also introduced an HF order set into our clinical system. It is now incumbent upon the providers to use it and we continue to engage with the care teams to use the order set. Using order sets can result in achieving higher core-measures compliance.

Finally, I want to speak to our future state. We hope to obtain funding to be able to risk stratify the readmission risk of our patients upon arrival to the ED, using demographics, socioeconomic factors, biomarkers, illness severity, comorbidities, and prior readmissions, amongst other factors. We feel that we can enhance the scope of services to the highest-risk patients using information technology rather than attempting to spread the highest vigilance to the entire cohort. E-reminders for clinical management like medication up-titration, repeat echocardiography, ICD placement, seasonal immunizations, and reminder visits—these are also some of the things that we could standardize through IT.

How have changes in reimbursement affected your ability to pursue changes in your clinical model?

For us, there has been incremental revenue by increasing visits, focusing on best practices, improving our coding and documentation of illness severity and comorbidities, and increasing the number of patients referred to social work for insurance and disability in those whose illness has progressed. We feel privileged to have support from the executive leadership and hospital stakeholders to focus on clinical best practice and improved care, so luckily we skipped any discussion about losing revenue by staving off readmissions. My understanding is that we will not be paid for readmissions in the future, so to us, the future is now.

What advice would you give to other clinicians interested in pursuing improvements in the model of care?

Do not wait for the promise of resources to start. We didn’t. Organize in such a way that you will quickly prove that your work needs increased support to achieve even bigger wins. Eliminate silos: create an empowering environment for nurses, physicians, and allied staff to have a significant role in engaging with the patient. Decide on how to measure your success so that resources may be allocated at each benchmark. Share information and adopt best practices.

What is next for your program?

Ideally, we would like to automate several processes. Our nurses spend a great deal of time on the phone with the patient. I would not want to replace that but rather complement it with some automated features to receive BP, weight, and symptoms through remote monitoring. We look forward to being able to stratify readmission risk in our patients from the time they hit the ED; this way, we can focus on the high- and highest-risk patients. I hope to have access to on-site palliative care. This should further reduce mortality and improve EOL care. The most challenging patients for us, as a program, are those who are discharged to a nursing home. By failing to have immediate and regular follow-up, the risk of readmission is increased. I hope to push for a palliative care pilot program at the nursing home our hospital system operates. For now, we will prioritize getting a readmission risk e-tool first. My hope is to have a cadre of nurses go out to the homes of the patients, with highest risk beyond what home care can offer. For now, our team will continue to welcome our patients back—as long as they are outpatients!

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, Demography, Health Literacy, Comorbidity, Disease Management, Home Care Services, Patient Discharge, Substance-Related Disorders, Immunization, Biomarkers, Outpatients, American Recovery and Reinvestment Act, Medicare, United States, Echocardiography, Health Care Reform, Nursing Homes, Medicaid, Diuretics, Electrophysiologic Techniques, Cardiac, Caregivers, Palliative Care, Heart Failure, Diet, Nutritionists, Defibrillators, Implantable

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