Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program

Carolinas HealthCare System

Transforming the Office Management of Heart Failure

Using the Chronic Disease Model in a Family Medicine Residency

ProgramRhett Brown, M.D.

Janice Huff, M.D.Eric Schneider, Pharm.D.

Department of Family MedicineCarolinas Medical Center

Charlotte, NC

Carolinas HealthCare SystemDepartment of Family Medicine

Acute Care Model

Patient Initiated: “Doc, I am sick!”

Brief

Limited planning by the clinician

Works well for the acute limited problem


Current status of Chronic Illness Care in the U.S.

27% of hypertensives are adequately treated 29% and 26% of diabetics have well controlled

lipid and blood pressure levels, respectively 35% of eligible patients with atrial fibrillation

receive anticoagulation 25% of people with depression are receiving

adequate treatment 50% of discharged CHF patients are

readmitted within 90 days


Chronic Illness

100 million persons in the US have at least 1 chronic illness

50 Million have more than 188% over age 65 have at least 1

chronic illness22% over age 65 have 4 chronic

illnesses


Quality Chasm

Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care

Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards


System Change ConceptsWhy a Chronic Care Model?

Emphasis on physician, not system, behavior

Characteristics of successful interventions weren’t being categorized usefully

Commonalities across chronic conditions unappreciated.


Knowledge versus Performance

Physicians know how to treat chronic diseasesThey know what tests should be

ordered and what medications should be prescribed

What services are actually being provided fall far short of best practice standards

We have a systems problem


The Watchword

Systems are perfectly designed to get the results they achieve


Remember:

We cannot work harder (systems are perfectly designed to get the results they achieve)

We must work SMARTER! We must work as a TEAM!

We must change OUR system


Chronic Care Model

ProductiveInteractions

Prepared,Proactive

Practice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community Health Care Organization

Informed,Activated

Patient


Our Clinical Transformation

Why HFRelatively small populationImpact on our health care system is

largeWell defined and accepted guidelinesEnergy within our hospital system for

improved outpatient management


Our Clinical Transformation

Determine best practice benchmarks and work to decrease inter-physician variability

Researched published data on best HF outpatient management system design

Developed a concept for an improved healthcare delivery model


Clinical Transformation Committee

AdministrationClinicians / Support

staff EducationResearch

Information SystemsNursingPharmacyCommunity Resources

Clinical Transformation Committee is multidisciplinary and meets monthly.

Key members:

Steering committee meets weekly to maintain momentum and monitor progress


Registry Definition

A computerized chronic disease registry is a computer

application to collect and manage condition-specific data

for a group of patients in order to support organized clinical care.


Critical Features of a Registry

Identification of patients with a common illness

Capture data elements electronicallyReal-time availabilitySearchableLinked to established guidelinesFeedback to providersEnhance generation of letters to patients


Registry Functions

Patient Informationentered into Registry

Point of care datafor patient visits

Status reports provide clinician feedback

Identify patients needing follow-up

care


Why Use a Registry?

Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care

Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards

The registry is one way to narrow the chasm


Why Use a Registry?

1. Ensure regular follow-up2. Ensure use of evidence-based guidelines3. Provide reminders for clinicians (and patients)4. Facilitate planned care visits5. Monitor performance of practice team6. Enable population management7. Enable task delegation to team members

…TO CHANGE SYSTEMS


CVDEMS Flow Sheet


CVDEMS Visit Note


CVDEMS Visit Note


CVDEMS Visit Note

History / Physical Examination Assessment of clinical signs/ symptoms of volume overload Cardiac examination Assessment of activity level (NYHA Class) and Disease stage (AHA/ACC Stage)

Tests / Procedures Weight, Blood pressure, Heart rate measurement BMP (q12 months, or as clinically indicated) Assess LVF (Change in clinical status or clinical event/treatment with significant effect on cardiac function)

Education Continue Heart Failure patient education plan Avoidance of patient behaviors that may increase the risk of HF

Medications Review current medication regimen for the presence of medications known to affect HF Heart failure medications as appropriate (see algorithm)

Self Management Training Update Heart Failure action plan Collaborative goal setting

Needs Assessment Assess patient needs and review community resources. Refer as appropriate


CVDEMS Flow Sheet


Services Needed/Recommendations


CVDEMS Decision Rules

LDL Serum creatinine Serum potassium Aspirin therapy ACEI / ARB therapy Beta Blocker therapy Statin therapy Spironolactone therapy Hydralazine/Nitrate

Coumadin in A Fib CTC Study Consent Assessment of LVEF ECHO Heart Failure

Education Pharmacy Consult Pneumovax Influenza Vaccine


Decision Tools Treat hypertension Encourage smoking cessation Treat lipid disorder

Encourage regular exercise Discourage ETOH & illicit drug use

Stage A Stage B Stage C Stage D

High risk for HF NYHA IVNYHA IIINYHA IINYHA I

consider ACEI ACEI (preferred) or ARB in ALL

patients*

discontinue NSAID’s, CCB, metformin, antiarrhythmics, Actos/Avandia*

Cardiology Referral

consider -Blockers in

select patients*

consider hydralazine

(25mg TID titrate to 100mg QID)

PLUSisosorbide DN

(10mg TID titrate to 80mg TID)

in patients unable to tolerate ACEI/ARB

ACEI (preferred) or ARB*(hydralazine + isosorbide DN in patients

unable to tolerate ACEI or ARB)AND

-Blockers* in ALL patients

Loop diuretic (ALL patients) as needed for fluid control

consider digoxin(target concentration <1.0 ng/ml

consider aldosterone antagonistspironolactone 25 mg daily (preferred) or

epleronone (Inspra®) 25-50mg

ACEI or ARB in ALL patients*

Loop diuretic for fluid control in ALL

patients

consider digoxinand aldosterone

antagonist

may need mechanical assist,transplantation,continuous IV inotrope infusions,HOSPICE care


Services Needed/Recommendations


Patient Goal Setting






Heart Failure Action Plan

Analogous to an Asthma action plan

Part of patient self management component

Heart Failure Action Plan YOU are the most important person in the management of your heart failure. As part of your medical care team, we will guide you and offer support in the management of your heart failure. The following plan will help you monitor your heart failure and take appropriate actions.

ALL CLEAR CONTINUE YOUR TREATMENT PLAN Your heart failure is stable You should have:

No change in the swelling in your feet/ankles

No change in your breathing No change in your ability to

exercise or perform your daily activities

No more than a 1-2 pound increase in weight since yesterday

Medications: Special Instructions:

CAUTION DO THE FOLLOWING Your heart failure is getting worse You may have:

An increase in the swelling in your feet/ankles

More difficulty breathing, especially when you lie down

More difficulty in your ability to exercise or perform your daily activities

More than a 3-5 pound increase in weight since yesterday

Call your Care Coordinator at 704-446-1000

DANGER CALL YOUR DOCTOR Your heart failure is worse and you need to see your doctor. You may:

Have an inability to catch your breath

Feel severely tired or weak Have more than a 5 pound increase

in weight since yesterday Have chest pain that is new or

worse than usual Be unable to perform daily activities

that you were able to do yesterday

If during business hours: Call your Care Coordinator at 704-446-1000 After hours or weekends: Call the Family Practice Doctor on call at 704-446-1000


Heart Failure Action Plan

Heart Failure Action Plan YOU are the most important person in the management of your heart failure. As part of your medical care team, we will guide you and offer support in the management of your heart failure. The following plan will help you monitor your heart failure and take appropriate actions.

ALL CLEAR CONTINUE YOUR TREATMENT PLAN Your heart failure is stable You should have:

No change in the swelling in your feet/ankles

No change in your breathing No change in your ability to

exercise or perform your daily activities

No more than a 1-2 pound increase in weight since yesterday

Medications: Special Instructions:

CAUTION DO THE FOLLOWING Your heart failure is getting worse You may have:

An increase in the swelling in your feet/ankles

More difficulty breathing, especially when you lie down

More difficulty in your ability to exercise or perform your daily activities

More than a 3-5 pound increase in weight since yesterday

Call your Care Coordinator at 704-446-1000

DANGER CALL YOUR DOCTOR Your heart failure is worse and you need to see your doctor. You may:

Have an inability to catch your breath

Feel severely tired or weak Have more than a 5 pound increase

in weight since yesterday Have chest pain that is new or

worse than usual Be unable to perform daily activities

that you were able to do yesterday

If during business hours: Call your Care Coordinator at 704-446-1000 After hours or weekends: Call the Family Practice Doctor on call at 704-446-1000


Care Coordinator

Adapted our current nurse triage positionsTwo RN Care Coordinators provide

continuityAdditional training in HF managementContact all HF patients after office visitsContact all patients on a regular schedule

based on HF severityFollow standing orders for management of

mild exacerbations


Patient Support Group

Initially held a patient focus groupFrom focus group recommendations

developedMonthly support groupHF disease educationOpportunity for residents to

participate in patient education and facilitating a group


Measure Outcomes

Hospitalization ratesQuality of life scoresMedication refill compliance


Lessons Learned

Difficulty and time required to navigate the IRB and RRC process

Communicating and achieving ‘buy-in’ when working with part-time providers

Cultural change takes TIME and PERSERVERANCE

Awareness of subcultures within our office

“Well, I do have this recurring dream that one day I might see some results.”

Health & Medicine

Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program