Designing Systems for Effective Heart Failure Care Ileana L. Piña, MD, MPH Professor of Medicine, Epidemiology and Population Health Albert Einstein College of Medicine Associate Chief of Cardiology for Academic Affairs Montefiore-Einstein Medical Center Bronx, NY Graduate VA Quality Scholar
The Landscape of Heart Failure Complex Hospitalizations are frequent Costs are high CMS rule penalties Patients are becoming more challenging Team effort
Clinical status AHF Recurs With Increasing Frequency and Contributes to Progression of Chronic HF Relationship of AHF to chronic HF Each AHF episode increases myocardial and other organ damage and rate of decline. NYHA classification NYHA I NYHA II NYHA III NYHA IV Compensated Chronically decompensated First myocardial injury H H HH H H H Acutely decompensated First episode of AHF with hospitalization DEATH DRAFT Risk of recurrence increases following initial AHF. 2 Risk of ischemic heart disease and cardiovascular disease also increases. 2 H, hospitalization; NYHA, New York Heart Association. 1. Gheorghide et al. Am J Cardiol. 2005;969suppl):11G-17G. 2. Lee et al. Am J Med. 2009;122:162-169. This confidential material [document] is for your information only. 5
Mortality (%) Risk of Death Is High Following 60 50 40 30 20 10 0 Hospitalization for AHF Mortality rates following hospitalization for AHF 1,2 In-hospital 60 90 days postdischarge After 1 year Within 5 years Risk of death increases progressively and independently with each HF event 1 Number of hospitalizations predicts mortality 3,4 DRAFT 1. Roger et al. Circulation. 2012;125:e2-e220. 2. Gheorghide et al. Am J Cardiol. 2005;96(suppl):11G-17G. 3. Lee et al. Am J Med. 2009;122:162-169. 4. Setoguchi et al. Am Heart J. 2007;154:260-266. 5. Chen et al. JAMA. 2011;306:1669-1678. This confidential material [document] is for your information only. 8
Mortality in HF Adjusted changes in outcomes between 1999 and 2011 13% Decline Krumholz HM, et al. Circulation. 2014;130(12):966-975.
Trends in HF: Mortality and Disposition 10
Heart Failure is the most common reason for 30 day reshospitalization Copyright CWRU-CME 2003 All Rights Reserved Jencks et al. N Engl J Med 2009;360:1418-28.
52% of heart failure patients are not seen in the first 30 days after a hospitalization Copyright CWRU-CME 2003 All Rights Reserved Jencks et al. N Engl J Med 2009;360:1418-28
Outcomes in Patients Hospitalized With HF 100 Hospital Readmissions 100 Mortality 75 50 25 20% 50% 75 50 25 12% 33% 50% 0 30 Days 6 Months 0 30 Days 12 Months 5 Years Mean LOS: 6.5 days Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3 Jong P et al. Arch Intern Med. 2002;162:1689 Annual mortality rate- NYHA class III HF- 12% [COPERNICUS DATA] NYHA class II HF- 7% [SCD-HeFT DATA]
Proportion of Hospitals Facing No Readmissions Penalty (Panel A) and Median Amount of Penalty (Panel B), According to the Proportion of Hospital's Patients Who Receive Supplemental Security Income. Joynt KE, Jha AK. N Engl J Med 2013;368:1175-1177.
Continuity of HF Care Reliable Care: Not Missing the Steps Black hole* Black hole* Hospital ED CCU Telemetry DC Early Post DC Outpatient Diagnosis Admit CCU? Acute Rx Evaluation IV Meds Oral Meds LV function Echo and/or Cath? Other Evaluation Tx to Floor Oral Meds Other Rx? Other eval Pt Ed F/U Disease Manage Right meds? Titration Pt Education Disease Manage Continuity Device? On right meds? On right dose? Volume status Re-assess EF Device? Self Manage? Other Issues? Fonarow GC. Rev Cardiovasc Med. 2006;7:S3-11. * Who is responsible????
Rehospitalizations in Heart Failure Nearly one in four patients hospitalized with HF is rehospitalized within 30 days of discharge Opportunity to Improve 30-day rates of rehospitalizations in HF have risen over the past 2 decades and vary widely by hospital, even after adjusting for case mix and other factors Opportunity to Improve Many HF hospitalizations are preventable, but effective strategies to prevent rehospitalizations are underutilized Opportunity to Improve 34
The Blame Game!
How to best transition care? Personal physician visits to home Visiting nurses trained in HF care Phone monitoring by a nurse/team Early/frequent visits to HF team Home monitoring (scale, phone systems, devices, internet based reporting) Let the patient decide when to call
Shouldn t it work? Is it a monitor or the system its deployed in? Who monitors the monitor? Who responds to monitoring signals and how? Do those that monitor and assess have authority to change therapy?
Hospital Variation in Early Follow-up After Heart Failure Hospitalization Median Follow-up Visit within 7 days = 37.5% 225 Hospitals Hernandez et al. JAMA 2010;303:1716-1722. 32
Study Conclusions Rates of physician follow-up within 1 week of discharge were low and varied substantially across hospitals. Patients discharged from hospitals with more consistent early follow-up with 7 days have lower risk of 30-day readmission. Enhanced transition planning and ensuring that patients are evaluated within a week of discharge represents an achievable target for hospital quality improvement.
H2H Core Concepts Post-discharge medication management. Patients must not only have access to the proper medications, they need to be properly educated on how to use them. Early follow-up. Discharged patients should have a follow-up visit scheduled within a week of discharge, as well as the means of getting to that appointment. Symptom management. Patients must recognize the signs and symptoms that require medical attention, as well as the appropriate person to contact if those signs/symptoms appear.
Understanding health care as a system How we improve what we make What society needs How we create, make health care
Transitions of care beyond the front door: Wishful thinking!
Transitions of care beyond the front door: Reality
7-10 day visit: Why may it not work What processes occur? Information obtained/acted upon Changing course of therapy Uptitration of evidence based care Patient education---who delivers?
Brown Bag clinic»a Montefiore initiative for HF patients to improve transitions of care post-discharge
Montefiore THE UNIVERSITY HOSPITAL FOR ALBERT EINSTEIN COLLEGE OF MEDICINE Brown Bag Clinic: feasibility 7-10 days from discharge for a HF admission Pharmacists trained in HF Physician on standby See patient if any problems or symptoms Serve as resource KCCQ administered Pro-BNP drawn if none at discharge. Patient education with MMC booklet Medication reconciliation Medication up-titration per protocol and Guidelines.
Montefiore THE UNIVERSITY HOSPITAL FOR ALBERT EINSTEIN COLLEGE OF MEDICINE Medication Reconciliation Clinic Flow Staffed by pharmacists Clinical pharmacists as preceptors Physician available on standby Symptom evaluation (vitals, questionnaire) Focus on medications Education, self-management tools, pill box fills One half day per week 6 slots, 1hr each Currently 8% readmission rate if seen in BBC
Montefiore THE UNIVERSITY HOSPITAL FOR ALBERT EINSTEIN COLLEGE OF MEDICINE Barriers Obtaining the right number of patients Finding patients currently in hospital for HF Varying # s by DRG Which ICD codes to use Multiple initiatives not well coordinated Referrals to BBC HF Attending stand-by during BBC other than Dr. Piña Support from physicians/housestaff/pa s.
SERIOUS Model for Medication Reconciliation Solicit (from patient) - Medications and allergies from patient at each encounter, including all medications and herbal supplements - Obtain information from other pharmacies if needed Examine - At each inpatient and outpatient encounter - Look for discrepancies in doses, frequencies between list and reported regimen Reconcile - Compare home list and list in medical record, make changes to make them match as appropriate - Reconcile with interactions and allergies and take appropriate actions Inform - Educate patients and caregivers about indications and adverse effects of medications Optimize - Optimize medication doses to target guidelines or to improve symptoms - Reduce medications if appropriate to address polypharmacy or improve adherence Update - Update list with appropriate changes Share - With patient/caregiver when leaving and all other providers Hoover D. IHI Quality Improvement Forum 2008. [Abstract]
Identify The Vulnerable patient Identify the vulnerable patient at discharge Schedule see you in seven days visit/brown bag clinic visit One half day per week 6 slots, 1hr each Bring ALL their medications from home- including rx medications, OTC, any medications which are expired, no longer used, and any reserve supplies. **ALL Pictures taken and used with explicit permission of patient
Identify the problem OTC/Herbs Active Rx Expired/duplicates Under the counter - my husbands NTG for CP
Typical List of Meds: BB Clinic
Patient education Educate patients/caregivers about indications and adverse effects of medications Patient education booklet: Living with Heart Failure Update Med list in EMR Letter sent to PMD/Cardiologist about changes made/updated med list during the clinic Next appointment scheduled
Brown Bag Clinic: Better Adherence Methods
30 Day Readmissions BB: 8 readmits <=30 days ---8.3% 4 for HF (50%) Controls: 16 readmits <=30 days 24.4%