The Saint Agnes Heart Failure Center

The Saint Agnes Heart Failure Center An NP and RN led program to engage patients in self-care Jae Patton, CRNP Deborah Hefty, RN,CHFN Theresa Kasper, RN, CHFN Heart Failure Center Saint Agnes Hospital, Baltimore

2 Presenters have no disclosures

Session Objectives Session attendees will be able to list three strategies for reducing heart failure readmissions Session attendees will be able to discuss the importance of an individualized approach to patient engagement in their own selfmanagement 3

Heart Failure: the problem > 5 million Americans diagnosed, $32 Billion/yr # 1 Cause of hospitalization in patients >65 # 1 diagnosis associated with 30 day readmissions 4

Heart Failure Disease Trajectory 50% mortality in 5 years 5

Systolic vs Diastolic 6

Definition of Heart Failure Classification I. Heart Failure with Reduced Ejection Fraction (HFrEF) Ejection Description Fraction 40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date. II. Heart Failure with Preserved Ejection Fraction (HFpEF) 50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF. b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.

Classification of Heart Failure A B C D ACCF/AHA Stages of HF At high risk for HF but without structural heart disease or symptoms of HF. Structural heart disease but without signs or symptoms of HF. Structural heart disease with prior or current symptoms of HF. Refractory HF requiring specialized interventions. None I I II III IV NYHA Functional Classification No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

Heart Failure Admissions/Readmissions Worsening of disease, co-morbid diagnoses Complexities of Self Care diet and medications are complicated More difficult in patients with poor social determinants of health Financial, social, family responsibilities, substance abuse, health literacy all potential barriers to Self Care 9

What works?? Multidisciplinary team care! multidisciplinary heart failure clinic interventions currently have the best evidence for reducing allcause readmissions and mortality up to 6 months after an index hospitalization for persons with heart failure. Feltner C, et al. Transitional care interventions to prevent readmissions for persons with heart failure. Ann Intern Med. 2014; (160): 774-784. 10

11 The Saint Agnes Heart Failure Center : A multidisciplinary disease management clinic serving patients since 2005

Saint Agnes HFC: Our patients 44% reside in Health Enterprise Zone zip codes (West Baltimore, often poor social determinants of health, higher death rates from CV disease) 64% African American Age range from 20s-90s 12

Saint Agnes HFC: Patients with range of socioeconomic backgrounds Poorest of the poor, active drug users, homeless and marginally housed Working class/ working poor patients who do physical labor, often marginally insured Wealthy (small population) often our oldest patients (80s and 90s) 13

Our team Kabir Yousuf, Medical Director and Champion Allison Mackenzie, Administrative Director Jae Patton, NP supervisor Kelly Gayed Heart Failure Coordinator, Clinic Nurse Practitioner Heart Failure RNs Deborah Hefty, Theresa Kasper, Jessica Harrison Nurse Navigator open position Front office Staff - Shannon Crosland, secretary; Rashawnda Robinson, PSR/MA And most recently our Chaplain, Sister Louise Busby 14

Physician Champion and Medical Director Kabir Yousuf, MD Important to establish trust with other physicians in our hospital community Expert medical back-up while NPs and RNs run the daily operations, a medical director with expertise in HF allows us to take sicker patients 15

Heart Failure Coordinator Bridge to Inpatients Kelly Gayed, CRNP Role originally started as Core Measures sheriff now Identifies HF patients while they re in-house not always clear on admit (Abstracted list daily of patients with HF, other diagnoses) Identifies high risk inpatients 30 day readmits, high utilizers, newly diagnosed Ensures inpatient staff have the tools they need for bedside teaching Participates in care plan development on High Utilizer Task Force 16

Heart Failure Nurse Navigator - Patients Bridge to Follow Up Role originally developed to address 30 day readmissions Evolved to focus on barriers to care that result in poor patient outcomes Works with Coordinator to identify inpatients with heart failure Bridges patients who qualify to Heart Failure Center Makes phone contact with ALL patients discharged with heart failure diagnosis to ensure they have appropriate follow up Follows these patients for a minimum of 30 days post discharge Identifies resources for HFC patients with significant barriers to care 17

18 The HFC Vision: Keeping Heart Failure Patients at Home, Improving their Quality of Life through Positive Engagement

Compliance? Adherence? We like engagement! A positive working relationship with the health care provider may result in improved adherence. Wu JR et al. Factors influencing medication adherence in patients with heart failure. Heart Lung 2008;37:8-16. The working alliance is important in medical treatment, as it is associated with patient adherence and satisfaction. Fuertes JN et al. The physician-patient working alliance. Patient Education and Counseling 2007; 66: 29-36. Several studies have documented that more highly activated patients consistently report more positive care experiences. Hibbard JH, Greene J. What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Affairs 2013; 32: 207-214 19

HFC Team: our day Staffed by NP/RN - Medical director as back up Checklist Team Rounds all hands on deck! Scheduled visits medication titration and follow up, patient education Preventing PAUs ED admit prevention program, phone triage/ diuretic titration, or urgent diuresis if needed 20

EF: % Ischemic Non-Isch Diastolic Other Last Appt: / / Summary: BP HR Recent ED/Hosp: Check-In Insurance No Concerns Concerns Identified Notes/Comments Triage Labs In House Send Out Check Today Provider Patient Goals Identified Needs Update SCD Risk ICD Reeval EF No ICD N/A Beta Blocker At Goal/Maxed Start/Up Titrate On Hold ACE/ARB At Goal/Maxed Start/Up Titrate On Hold Ald Antagonist At Goal/Maxed Start/Up Titrate On Hold Bidil/Combo At Goal/Maxed Start/Up Titrate On Hold Diuretic Lasix Bumex Metolazone Cardiac Rehab Participating Refer Completed N/A Advanced Care Plan Today: Has AD Scanned? Y / N No AD Video Today Palliative C/S RN Education Low Na Diet Symptoms Meds/Pill Box Activity Fluid Goal Notes: Navigator Social Transport Medication Food Other Follow-Up Primary Care Cardiology Mental Health Other

Medical Management: the NPs Guideline Directed Medical Therapy (GDMT): getting Heart Failure core medications to goal *quickly* and safely ACE inhibitors, ARBs, Entresto Beta blockers (Carvedilol, Metoprolol succinate) Spironolactone Bidil in African Americans (already on ACE I, beta blocker) 22

Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTs GDMT RR Reduction in Mortality NNT for Mortality Reduction (Standardized to 36 mo) RR Reduction in HF Hospitalizations ACE inhibitor or ARB 17% 26 31% Beta blocker 34% 9 41% Aldosterone antagonist 30% 6 35% Hydralazine/nitrate 43% 7 33%

Sacubitril/Valsartan: A few words about the new kid on the block 24

Titrate to patient symptoms Don t be afraid of low blood pressures particularly in systolic heart failure patients! 25

Pharmacologic Treatment for Stage C HFrEF

Medical Management: the NPs GDMT: Assessment of Sudden Cardiac Death risk - Ischemics 6 weeks - Non-ischemics - 3-9 months Referral for re-evaluation of ejection fraction, need for ICD or CRT-D device 27

Device Therapy for Stage C HFrEF (cont.) Recommendations COR LOE ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-mi with LVEF 35%, and NYHA class II or III symptoms on chronic GDMT, who are expected to live 1 year* I A CRT is indicated for patients who have LVEF 35%, sinus rhythm, LBBB with a QRS 150 ms ICD therapy is recommended for primary prevention of SCD in selected patients with HFrEF at least 40 days post-mi with LVEF 30%, and NYHA class I symptoms while receiving GDMT, who are expected to live 1 year* CRT can be useful for patients who have LVEF 35%, sinus rhythm, a non- LBBB pattern with a QRS 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. CRT can be useful for patients who have LVEF 35%, sinus rhythm, LBBB with a QRS 120 to 149 ms, and NYHA class II, III or ambulatory IV symptoms on GDMT CRT can be useful in patients with AF and LVEF 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or rate control allows near 100% ventricular pacing with CRT I I IIa IIa IIa A (NYHA class III/IV) B (NYHA class II) B A B B

Medical Management: the NPs Volume evaluation Orthostatic vitals Oral diuretic titration IV Diuresis METs back-up 29

HFC Case Study: Urgent diuresis 54 yo AfAm female NICM, EF 10%, C Cath in past yr neg for CAD. Na indiscretion at Memorial Day picnic - presents with dyspnea, PND, orthopnea, abd bloating, 11 lb wt gain VS: HR 120s, BP 90/60, RR 30s, O2 sat 88% PE: CV: S1S2 rapid, regular (ST on monitor), JVD 10 cm Pulm: fine crackles ½ way up bilat Abd: distended, hepatomegaly Ext: 2+ pitting edema to the knee 30

HFC Case Study: Urgent Diuresis Interventions IV/O2/ Monitor Stat labs (BUN/creat stable, K 3.6, BNP 2400) Lasix 80 mg IV x1, Kdur 40 meq po x1 3 hours later, 1900 ccs out, sig symptom relief, HR 90s, BP 100/70s, O2 sat 94% on RA Increased home diuretic, saw again early the next week, wt down 8 lbs, BUN/ creat stable. Feeling much better Admission averted! If our patients show up in any ER, they re getting admitted. We have to keep them out! Kabir Yousuf, MD 31

Medical Management: the NPs Ensuring treatment for pertinent co-morbid conditions, referring to appropriate specialists CAD Hypertension now thought to be #1 driver HF Pulmonary HTN Sleep apnea Afib, VT, other cardiac arrhythmias COPD Endocrine disorders diabetes, thyroid AICD and Pacemaker management/ SCA risk 32

Medical Management: the NPs Evaluate for worsening prognostic indicators Multiple exacerbations/ hospitalizations - >2 in one year Diuretic Resistance/ High diuretic requirement Hypotension resulting in d/c of core heart failure medications Hyponatremia Elevated BUN Cardiac cachexia Multiple AICD shocks or worsening arrhythmias Referral advanced therapeutics (LVAD, transplant) or palliative care/ hospice 33

Transitions of Care in Heart Failure: A Scientific Statement from the American Heart Association Registered nurses are leaders in delivering patient self-care education; however, the level of nurse understanding of chronic HF self-care principles must match patient needs. Albert, NM et al. Transitions of care in heart failure: A scientific statement from the American Heart Association. Circ Heart Fail. 2015; 8:000-000.DOI:10.1161/HHF.0000000000000006. 34

Heart Failure Teaching: the RNs AAHFN Certification Individually tailored to patients needs, interests, health literacy level Best of AHA, ACC, also interactive/ home grown education Videos made in HFC Self Management Education 35

Heart Failure Teaching: the RNs Engaging and Activating patients in Self-Care Daily weights fluid is heavy Symptom Recognition DOE/SOB Fatigue, activity intolerance LE and Abd edema PND/orthopnea 36

Heart Failure Teaching: the RNs Engaging and Activating patients in Self-Care The Low Sodium Diet: Patient s first question, most significant anxiety What can I eat?? 37

Real world pitfalls, real world strategies 38

The good, the bad and the better 39

Heart Failure Teaching: the RNs Engaging and Activating patients in Self-Care Medication Management 40

Case study: Pill boxing prevents readmissions 80 year old AfAm man, h/o NICM, EF 40%, HTN, Afib, diabetes, dementia 5 admissions between June 2013 August 2013 Admit 1: Hypoglycemia, Afib RVR Admit 2: Digoxin toxicity Admit 3: Syncope, hypoglycemia, Afib RVR Admit 4: *CHF exacerbation*, hypoglycemia Admit 5: Hypoglycemia (5 days after discharge patient s insulin finally stopped this admission) Admit 4 is index heart failure admission. Admit 5 is 30 day readmit patient referred to HFC. 41

Case Study: Pill boxing prevents readmissions First visit at 2 pm patient hasn t taken any medications nurses give pill boxes, explain how to use. Patient stable on all medications seen for minor medication adjustments over the next year. Wife has a CVA. Presents 4 times over a period of 2 months in worsening heart failure, requiring oral diuretic adjustment. Nurses have him bring in medications find he is not on furosemide doesn t have the bottle Nurses offer to assist with pill boxing. 42

Case Study: Pill boxing prevents readmissions Bi weekly help with pill boxing instituted Nurses supervise patient filling box, ensure all prescriptions filled as ordered. Nurses observe patient sometimes misses medications recommend change to long acting medications. Patient now rarely misses medications, no further HF exacerbations, despite occasional dietary indiscretions. 43

Heart Failure Teaching: the RNs Engaging and Activating patients in Self-Care Activity Progression Gentle ROM Walking program Thera - bands Cardiac Rehabilitation 44

Heart Failure Teaching: the RNs Engaging and Activating patients in Self-Care Time for a little controversy Fluid restrictions are not for everyone! per 2013 ACC/AHA Guidelines Only for Stage D or patients with Hyponatremia 45

Admission Prevention The whole team! Phone Triage early symptom recognition/ managing diuretics Urgent in-clinic diuresis Pill boxing a stabilizing force for select patients Palliative Care, referrals HU Task Force Care Plans And now - ED to HFC Admit Prevention 46

Palliative Care Why so important in Heart Failure? 50 % of ALL readmissions happen in the last two months of patient s lives 47

Palliative Care: the HFC approach Advance Care Planning videos grant from the Saint Agnes Foundation Courageous Conversations staff trainings, relationship with Gilcrest Hospice Our chaplain, the wonderful Sister Louise Busby Palliative diuresis and inotrope therapy 48

Our results patient satisfaction The Heart Failure Center staff helps me take my medications properly. 92.9% Agree Strongly * The Heart Failure Center helps me understand how to eat a low sodium diet. 92.9% Agree Strongly 7.1% Agree Somewhat The Heart Failure Center has helped me stay out of the hospital. 85.7% Agree Strongly * 7.1% Agree Somewhat The Heart Failure Center has improved my quality of life. 78.6% Agree Strongly * 14.3% Agree Somewhat I find it easy to get my appointments at the Heart Failure Center. 85.7% Agree Strongly 14.3% Agree Somewhat The staff members at the Heart Failure Center care about my well being. 100% Agree Strongly 49

Our results The HFC net promoter score 100% of respondents would recommend us to family and friends. I really LOVE the staff; friendly and caring! 50

Our results Patient Quality of Life Minnesota Living With Heart Failure Score Measurement of Quality of Life and symptom burden. Scores from 0 105, with 105 being worst QOL and symptom burden 69% of patients saw an improvement Average improvement of 35 points 51

Maybe our results? So many current interventions however Heart Failure readmissions down at St Agnes Nation-wide readmission numbers ~ 30% Saint Agnes Heart Failure readmission ~ 15.86% July 2016: 5.1% readmission rate! 52

Future directions COPD - HFC Model, staffed with RTs, NP Positive patient engagement Seasonal calls to patients Patient rewards program Trauma informed care Camden Model Motivational Interviewing Acceptance/nonjudgement 53

Want more Heart Failure Education? 54

Thank you! Questions / Comments Jill.patton@stagnes.org 56 October 3, 2016