Designing Systems for Effective Heart Failure Care

Ileana L. Piña, MD, MPHProfessor of Medicine, Epidemiology and Population Health

Albert Einstein College of MedicineAssociate Chief of Cardiology for Academic Affairs

Montefiore-Einstein Medical CenterBronx, 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

AHF Recurs With Increasing Frequency and Contributes to Progression of Chronic HF

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.

Risk of recurrence increases following initial AHF.2

Risk of ischemic heart disease and cardiovascular disease also increases.2

Relationship of AHF to chronic HF

Each AHF episode increases myocardial and other

organ damage and rate of decline.

NYHA I NYHA II NYHA III NYHA IV

H HHH

H HH

First myocardial

injury

First episode of AHF

with hospitalization

NYHA

classification

Compensated

Chronically

decompensated

Acutely

decompensated

Cli

nic

al s

tatu

s

DEATH

5This confidential material [document] is for your information only.DRAFT

Number of hospitalizations predicts mortality3,4

Risk of Death Is High Following Hospitalization for AHF

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.

0

10

20

30

40

50

60

In-hospital 60–90 days post-discharge

After 1 year Within 5 years

Mo

rtal

ity

(%)

Mortality rates following hospitalization for AHF1,2

8

Risk of death increases progressively and independently with each HF event1

This confidential material [document] is for your

information only.DRAFT

Mortality in HFAdjusted 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

Copyright CWRU-CME 2003

All Rights Reserved

Heart Failure is the most common reason for 30 day reshospitalization

Jencks et al. N Engl J Med 2009;360:1418-28.

Copyright CWRU-CME 2003

All Rights Reserved

52% of heart failure patients are not seen in the first 30 days after a hospitalization

Jencks et al. N Engl J Med 2009;360:1418-28

Outcomes in Patients Hospitalized With HF

Fonarow, GC. Rev Cardiovasc Med. 2002;3(suppl 4):S3

Jong P et al. Arch Intern Med. 2002;162:1689

0

25

50

75

100

20%

50%

30Days

6Months

Hospital Readmissions

0

25

50

75

100

50%

30Days

12Months

Mortality

33%

5Years

Mean LOS: 6.5 days Annual mortality rate-

NYHA class III HF-

12% [COPERNICUS DATA]

NYHA class II HF-

7% [SCD-HeFT DATA]

12%

50%

33%

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 CareReliable Care: Not Missing the Steps

Fonarow GC. Rev Cardiovasc Med. 2006;7:S3-11.

Outpatient

• On right meds?

• On right dose?

• Volume status

• Re-assess EF

• Device?

• Self Manage?

• Other Issues?

Early Post DC

• Right meds?

• Titration

• Pt

Education

Disease

Manage

• Continuity

Device?

DC

• Oral Meds

• Other Rx?

• Other eval

• Pt Ed

• F/U

• Disease

Manage

CCUTelemetry

• IV Meds

• Oral Meds

• LV function

• Echo and/or

Cath?

• Other

Evaluation

• Tx to Floor

HospitalED

•Diagnosis

•Admit

•CCU?

•Acute Rx

•Evaluation

* Who is responsible????

Black hole*

Black hole*

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

• 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.

Study Conclusions

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.

How we improve

what we make

What society

needs

How we create,

make health care

Understanding health care as a system

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 Montefioreinitiative for HF patients to improve transitions of care post-discharge

MontefioreTHE UNIVERSITY HOSPITAL FORALBERT 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.

MontefioreTHE UNIVERSITY HOSPITAL FORALBERT 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

MontefioreTHE UNIVERSITY HOSPITAL FORALBERT 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

Expired/duplicates

“Under the counter”- “my husbands NTG for CP”

OTC/Herbs Active Rx

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%