In Lincoln, NC, a small rural community about 45 miles from Charlotte, heart failure (HF) patients and their doctors at Carolinas HealthCare System’s Carolinas Medical Center’s Lincoln location are finding that virtual connections can help them achieve improved outcomes and significantly reduce readmission rates. Their achievements come as a result of a virtual clinic, an innovative variation of the Heart Success Transition Clinics, which are part of Heart Success, a program developed by Carolinas HealthCare System’s Sanger Heart & Vascular Institute.

Heart Success is a long-term outreach program developed by the Institute to standardize, integrate and optimize care of HF patients. A key element to the program’s success has been the transition clinics, which focus on assisting HF patients during their first four to six weeks after hospital discharge.

“That transition time from the inpatient to outpatient world is what we consider one of the biggest risk times for the HF patient,” said Sanjeev Gulati, MD, FACC, director of Advanced Heart Failure and Transplant at the Sanger Heart & Vascular Institute. “Yes, one of our goals was to reduce readmission rates, but most importantly, we wanted to make sure that patients would get the highest standard of care and be set up for success once they left the hospital. Doing this required that we reduce variations in care and find better ways to enhance the connectivity between primary providers, the HF team and the patient.”

To help reduce variations in care and ensure that providers deliver consistent levels of care by following guidelines and best practices and using up-to-date options for their patients, the Institute developed and has maintained guidelines for HF patient care based on national guidelines and other key information. The documents are made available to patients’ primary care providers, whether a cardiologist or general practitioner, along with an outline of what has been done for the patient to that point and recommendations on what the next steps of care should be. It is hoped that providing these increased resources will help reduce variations in care that may be unintentional yet have clinical and financial impacts for a patient, Gulati explained.

However, before that final step back to the primary provider, the patient spends time with a multidisciplinary HF team at the transition clinic. The Heart Success Transition Clinics provide patients with a carefully coordinated four- to six-week transition during which they work with a HF team that includes a navigator, social worker, home health care worker, pharmacist, dietician, physician assistant, other specialty providers and someone from the IT department.

Taking the Next Step, a Virtual Clinic

 

The Heart Success Model: Engage patients and their families more effectively to increase adherence to plan of care Reduce the variations in care Identify better ways to manage these high risk patients across the continuum Identify and provide appropriate resources and tools for the providers in the System to manage these complex patients

The Sanger Heart & Vascular Institute developed the Heart Success Transition Clinic concept to improve patient care and outcomes once HF patients were discharged from the hospital and to reduce their readmissions. Yet, many HF patients living in rural communities couldn’t take full advantage of the transition clinics if doing so required them to travel to the larger city. A more innovative approach was needed for these patients, and the answer came in the form of the virtual Heart Success Transition Clinic in Lincoln County, which saw its first patient in June 2013.

Telemedicine to follow patients remotely may not be new, but its use to sustain a virtual clinic is unique. In a rural community many HF patients are unable physically or economically to travel long distances for their care. With the virtual clinic, these patients gain access to the full range of care available with a multidisciplinary team at the quaternary/tertiary center for advanced care.

“Offering the Heart Success Transition Clinics virtually allows us to care for an increased number of patients, including those who may not be able to receive the same level of care otherwise,” said Gulati.

According to Sanjeev Shah, MD, FACC, Advanced Heart Failure and Transplant Cardiology, at the Sanger Heart & Vascular Institute’s Lincoln location, having the virtual clinic has made a remarkable difference for this rural community. With the virtual clinic, the patients and their physicians have access to resources across the entire Carolinas HealthCare System —comprised of more than 791 care locations — many of them resources that are not and cannot be available at every site, particularly the smaller facilities.

In virtual visits, patients are able to meet with the HF-dedicated pharmacists or dieticians and other specialist providers. One nurse at the Lincoln clinic, who is dedicated to the patients with virtual visits, guides patients to the virtual clinic room and stays throughout the visit. For non-ambulatory patients who cannot come to the clinic, the virtual clinic goes to them with the help of a home health care provider and a laptop computer.

Building a Strong Team and Consistent Message

All members of the HF team, including the patient, are important to a patient’s eventual success, but the Heart Success program’s patient navigator plays a major role in reducing variations in care and communicating a consistent message to the patient, the patient’s family and other providers. It is the patient navigators who are the bridge for carrying the message of consistency to the patient, the patient’s family and to providers as well. According to Dana Harris, RN, CHFN, navigator at Carolinas HealthCare System’s Carolinas Medical Center, the patient navigator, usually a nurse, meets with HF patients within the first 24 to 48 hours of their admission to the hospital. He/she then begins the process of explaining and answering questions about HF and explains the Heart Success program’s transition clinic and its purpose.

“Making this early connection is important in building trust and helping the patients realize they are not alone,” said Karen Cloninger, MD, FACC, of the Sanger Heart & Vascular Institute’s Lincoln location. Patient navigators visit patients frequently during their hospital stay and if patients wish to participate in the Heart Success program, help them meet their teams or make the arrangements for home health care and virtual visits. Once a patient is discharged, patient navigators continue the patient contact by phone and virtual visits, addressing patient concerns, answering questions about medications and more. For example, Eugenia Ashwood, RN, navigator at Carolinas Medical Center’s Lincoln location, conducts once-a-month education programs for patients and their families featuring specialists such as electrophysiologists. She also helps other hospital staff understand HF patients and how their needs may be different, too.

Getting Positive Results

The virtual Heart Success Transition Clinic at the Lincoln location and the other transition clinics are already producing positive results as are evidenced by drops in readmission rates. At Lincoln, rates have dropped to less than 10 percent. Shah and Cloninger credit this success to the early planning and successful development in the original clinic concept at Carolinas Medical Center. Shah adds that planning ahead, working as a team, realizing that we all have the same goal, and having a good navigator on the team were critical. Sending key people, such as their nurse navigator, for training at the quaternary-tertiary center in Charlotte was important, too.

“The virtual clinic in Lincoln carries an even greater importance than its immediate benefits to the local community,” said Cloninger. “I think that national data would reveal that a larger percentage of HF patients live in rural areas than in cities. This kind of program could have a tremendous impact on their care in the future and a huge impact on treating HF successfully, particularly if we can show carriers that this kind of treatment is valuable.”