2/20/2015. KPNW Region. NW Service Delivery History

Transcription

1 KPNW Region Service area=17 counties in 2 states; approximately 504,400 members Building an Integrated Heart Failure Transplant Program The KPNW Experience Kathy A. Crispell, MD, FACC, Department of Cardiology Kaiser Sunnyside Medical Center Chief of Staff/Chief Medical Officer NW Service Delivery History 2003: Heart Transplant totally contracted out (OHSU) Advanced Heart Failure care contracted out (OHSU) Heart Failure RN case management program with physician oversight in place. 2004: Proposal to internalize the care of our posttransplant patients, build an Advanced Heart Failure Program 2006: Began recruiting and organizing resources to support such programs 2006: New relationship with Transplant Coordinator Re established our relationship with our contracted Transplant Center Recruited a MSW for the department of Cardiology to support Heart Transplant and Heart Failure patients Recruited a hospitalist and mentored that physician to be the physician overseeing the Case Managed Heart Failure Program 2009: started making plans to implant Ventricular Assist Devices 1

2 Quality Process Rigorous Quality Process CV Surgery Internalization Interventional Cardiology Internalization Physician Leadership, Expertise and Ownership Standardization using Protocols Simulations Debriefs Improvements based on simulations and debriefs This has led to: KPNW Cardiac Surgery Program exceeding national standards as evidenced by maintaining a 3 Star (top score) Composite Quality Rating from the Society of Thoracic Surgeons (STS) for CABG beginning in July 2009 through June Star Composite Quality Rating from the STS for Aortic Valve Replacement surgery from January 2011 through June Star Composite Quality Rating for CABG and AVR combined surgery from January 2011 through June Consumer Reports named KSMC 1 of just 15 hospitals in the nation to earn top scores in both heart valve and bypass surgery NW Service Delivery History 2010: ABIM Advanced Heart Failure/Transplant Certification Repatriated the care of all of our heart transplant pts at year 3 post transplant (phased approach) 2011: Began building the Advanced Heart Failure/Mechanical Circulatory Support (MCS) /Transplant Team Recruited a Board Eligible AHF/Transplant Cardiologist Recruited a VAD/Program Coordinator Integrated our MSW, 2 Physician Assistants, imbedded hospitalist CV Quality Model used 2

3 NW Service Delivery History Integrated work flow 2011: Mechanical Cardiac Support (MCS) Program approved by senior leadership Contracted with VAD vendor Repatriated our four DT VAD patients from our transplant center, OHSU (Phased approach, Share Care) May 2012: our first destination VAD implant August 2012: our second destination VAD implant May 2012 December 2014: 5 DT VADs implanted 2015: repatriation of heart transplant patients at 1 year post Referrals Cardiology PCP Hospital Others AHF/MCS/Transplant Clinic Located on KSMC campus Staffed by Team members Weekly Clinical Conferences Treatment plans Clinic patients Inpatients Listed patients Integrated Work Flow AHF/MCS/Transplant Team All patients discussed at the weekly clinical meetings. Potential MCS candidates discussed at weekly Cardiac Cath Conference for general approval. Selection conference with AHF/MCS/Tx team members, palliative care physician, ad hoc physical therapy, nutrition Advanced Heart Failure/MCS/Transplant Team Members Kathy Crispell, MD Tim Jacobson, MD Ryan Morrissey, MD Barbara McKenna, RN, MSN, CNS Pam Montes, RN Siobhan Gray, MD Dr. Yong Shin, MD Patty Salvey Sunde, MSW Keith Stockbauer, RN 3

4 Weekly Clinical Conferences Guidelines for MCS Regional Transplant Coordinator Keith Stockbauer, RN Post transplant patients National Transplant Coordinator Stacey Lundholm, RN Pre transplant patients and post to 1 year Program Consultants OHSU colleagues Stanford colleagues Ad Hoc Consultants Palliative Care/Hospice Social Worker EP CHF Case Manager NYHA class IIIB or IV plus one or more of the following: LVEF <40% Inability to walk a block or less without DOE despite optimization of medical therapy and volume status MVO2 of 14 or less OR <50% age gender predicted with attainment of AT Inotrope dependence for > 14 days or IABP dependence for > 7 days Serum sodium of <136 BUN >40 Intolerant or refractory to ACEI/ARB or BB Diuretic dose >1.5 mg/kg of lasix equivalent One or more CHF related hospitalizations within 6 months CRT non responder Recurrent pulmonary edema within 6 months Weight loss due to cardiac cachexia Recurrent symptomatic ventricular arrhythmias requiring defibrillation Progressive cardio renal syndrome Progressive secondary pulmonary hypertension with right ventricular dysfunction MCS Relative Contraindications MCS Evaluation Renal failure with creatinine > Hepatic failure with Child s class B or C cirrhosis COPD with FEV1 < 40% predicted Significant cognitive dysfunction or significant mental illness Amyloid with multi organ involvement Active infection Significant chronic cytopenias History of bleeding precluding low level anti coagulation Limb threatening peripheral vascular disease BMI < 20 kg/m2 with prealbumin < 15 mg/dl Poor social support Poor or limited compliance with medical therapy Substance abuse within the past 6 months BMI > 40 Lietz risk score >16. RVSWI <300 mmhg x ml/m2. Critical cardiogenic shock with death expected within hours (Intermacs class 1). Pre Op Labs CBC BMP LFT s, albumin, pre albumin INR TSH ABO HIV As indicated: PSA Pre Op Testing/Procedures ECG CXR Echo Right Heart Cath ICD placement As Indicated: Coronary angiography Cardiac CT (LIMA localization) PFT s Head CT (Assessment for prior CVA) ) ABI s, assessment of peripheral vasculature Vascular ultrasound (AAA screening, EGD/Colonoscopy Mammography (age appropriate cancer screening) 4

5 MCS Lifelong care MCS End of Life Care Pre op Clinic Visits Advanced HF Clinic CV Surgery Clinic Social Worker Palliative Care Physical Therapy Post op Clinic Visits Weekly for 4 weeks Every other week until week 16 Monthly Every other Month Protocol in place for defibrillator deactivation Palliative Care/Hospice Collaboration MSW support Protocol in place for stopping VAD 4 VADs stopped by team members MCS Numbers Integration Evolution 58 Post Transplant Patients Followed 5 Total number of VADs implanted at KSMC 11 Total VAD implanted patients 4/11 Destination MCS patients 1/11 Long Bridge MCS patient 1/300,000=Estimated number of appropriate DT VADs implanted/population/year June 2014 Intermacs Report, J of Heart and Lung Transplant 2014:33 (6) 5

6 Integrated CV Programs The Vision CV Surgery KP Natl Tx AHF/MCS/Tx Structural Heart General CV Interventional Cardiology Electrophysiology OHSU Tx Other KP Regions and Service Areas Other AHF/Tx Programs CV Surgery Other KP Regions and Service Areas and Nat l Transplant Structural Heart AHF/MCS/Tx General CV Interventional Cardiology Electrophysiology OHSU Tx Other AHF/Tx Programs The Challenge Opportunities How can we as a national health care delivery organization integrate better in order to: Provide high quality care, in the most affordable manner possible, for small groups of patients who may benefit from high risk, very expensive therapies? Standardize the pre, intra and post op protocols as much as possible on a national level. Example=KP National Transplant Protocols Leverage our KP s multi regional presence and high national membership to create two or three regional hubs as VAD implant centers. Win win from both quality and affordability standpoint. European models in place. 6