Kick off Meeting November 11 13, 2015 MERCY CLINIC EAST COMMUNITIES Management of Patients with Heart Failure (HF)
Team Composition Justin Huynh, MD Internal Medicine, Physician Champion Mary Laubinger, RN, MSN Executive Director of Quality Laura Tuschhoff, RN, BSN Clinical Outcomes Manager Cathy Martin, RN, BSN, CCM Director, Care Management Christopher Keppler, CHTS PW Senior EMR Analyst Margaret Rechtien, GNP BC, CCM Project Manager Laura Pastrana, RN, BSN Nurse Care Manager HF Supportive Care Team Megan Geyer, RN, BSN Nurse Care Manager HF Supportive Care Team Lori Tasche, RN, BSN, CCM Nurse Care Manager HF Supportive Care Team Jean Young, RN, BSN Nurse Care Manager HF Supportive Care Team Multidisciplinary Readmission Task Force Team, with membership from both our hospitals and clinics.
HF Goals & Objectives What are your HF goal(s) and/or objective(s)? To reduce hospital readmissions for HF. To develop a systematic way to manage and improve care for patients with complex psychosocial and medical needs. To provide the right supportive care at the right time (e.g. virtual care in the patient s home, cardiac rehab, home health, palliative care, hospice, etc.). Where are you now? The 30 day HF All Cause Readmission Rate at our Heart & Vascular Hospital in St. Louis was 18.9% in CY 2014. Many of our end stage HF patients are admitted to hospice on the day that they die. We need a better way of bringing in supportive care services at the right time. In October 2015, we assembled a HF Supportive Care Team that consists of 4 RN case managers and 2 social workers. Their sole focus is on HF. Mercy opened the world s first Virtual Care Center in St. Louis on October 6, 2015. This will allow patients with chronic conditions, such as HF, to be monitored from their home by a physician on a daily basis.
HF Readmission Rate Jan Dec 2014
HF Intervention & Population Baseline Describe your target HF population(s) and how you identified them. Our emphasis will be on HF patients who are seen at our 96 bed Heart & Vascular Hospital and 980 bed Acute Care Hospital in St. Louis. In CY14, our 30 day HF All Cause Readmission Rates were trending up at these entities. Provide demographics on target population(s). Both urban and rural. Did you set up a HF registry to identify patients, collect additional data elements, etc? We have a HF registry in EPIC. Additionally, Optum TM One allows us to easily identify patients with HF. Describe what went on behind the scenes to implement this intervention? We saw a need to improve care, and assembled a Supportive CM Program for HF patients. This group began seeing patients in October 2015. What changes, if any, required in the workflow. We need to incorporate Virtual Care for home monitoring of HF patients. Addition of standing orders for medications adjusting in the home setting. We need a better way of utilizing supportive care services at the right time.
HF Intervention & Population Baseline How was healthcare information technology used in this intervention? Inpatient Care Path for Heart Failure (Epic) Daily Discharge Report (Epic) HF 30 Day Readmission Report (Epic) High Risk Readmission Report (Optum TM One) Describe how staff were involved in this intervention. The Inpatient Care Path for HF was designed using evidence based research to guide clinical practice. It is EHR integrated, and helps define the sequencing of timing of health interventions by outlining clear milestones and patient outcomes that must be met daily. Reports help our inpatient and ambulatory Care Management teams target HF patients. What methods were used to change physician practices? 1:1 education about in home care management support for HF patients. Data is shared via our hospital and clinic based committees. Provider scorecards are shared monthly. Medical directors, operations and our quality department perform triple aim rounds every 2 months in the primary care offices. During triple aim rounds, this team meets with providers face to face, to review and discuss their specific quality data. Key quality measures are also tied to provider performance and compensation.
Improvement Interventions Our Heart & Vascular Hospital has an inpatient heart failure service with a dedicated team for inpatient care This team does rounding on inpatients with HF, and provides discharge planning that includes transitions of care. Based on the patient s readmission risk assessment score, a follow up appointment is scheduled to occur between 2 7 days post discharge with a PCP or cardiologist. Embedded in our EMR (Epic), we have an inpatient care path for HF. The Inpatient Care Path for HF was designed using evidence based research to guide clinical practice. It helps define the sequencing of timing of health interventions by outlining clear milestones and patient outcomes that must be met daily. The focus of the pathway is to provide the highest quality of care to our patients, speed the delivery of care, minimize delays, reduce variation, manage complexity, foster appropriate resource utilization, and most importantly, improve quality and outcomes. Implementation of a pop up EMR (Epic) that alerts/communicates with any member of the healthcare team that comes in contact with this frail, HF patient. Design of an integrated careplan for all disciplines (inpatient/ambulatory) to access and use.
Improvement Interventions (continued) Assembling a team of ambulatory nurse care managers and social workers whose sole focus is on HF patients. This team provides in home and telephonic support. The home visit team tries to visit the patient within 24 hours of hospital discharge, and can see patients long term. A social worker is available to address complex social and/or financial needs. This service is FREE for the patient. The team also provides nursing home visits to monitor patient status. They are currently working on standing orders for diuretics, weights, pulse ox, BP, etc. Developing an interdisciplinary team, with a focus on high risk discharges and HF readmissions. This team began meeting weekly on October 15. Those at the table included: ED, Primary Care, Cardiology, Hospitalists, Nutrition, Home Care, Palliative Care, Hospice, Cardiac Rehab and the HF Supportive Care Team. This team discusses patient cases and examines any breakdown in the system which lead to a readmission.
Improvement Interventions (continued) Larger ambulatory care management team focuses on patients with less risk. Is an extension of our primary care clinic. This team provides in home and telephonic support and meets weekly with a medical director to review cases. Our HF Supportive Care Team provides transition of care phone calls, as well as in home monitoring of weight, BP and HF symptoms with telephonic and Interactive Voice Response (IVR) products. Patients with HF can submit vital signs, weight and take customized surveys via a home telemonitoring system. The HF Resource Center also provides telephonic disease management education to engage the patient in self management of their heart failure. NEW Virtual Care Center for home monitoring.
Measures Used What national clinical standards, if any, did you use as your guideposts and why? CMS readmission standards. Describe data sources and data collection processes, measures, and results. Mercy wide data on hospital readmission rates (CY 14 18.9%) Beta blocker for LVEF < 40% (CY14 69.29%) ACEI/ARB for LVSD in HF patients (CY14 100%)
Challenges or Obstacles What were/are your biggest challenges? Siloed, fragmented care and poor communication amongst our 980 bed acute care hospital, 96 bed heart and vascular hospital, cardiologists, hospitalists, PCPs, ancillary departments and supportive care teams. Changing the culture of ED utilization. Primary care, cardiology and patients are accustomed to using the emergency room for any potential signs of decompensation in HF. Approximately 70% of our admissions and readmissions for patients with HF are for comorbid conditions and diagnoses unrelated to HF. Psychosocial factors have been the source of many of these admissions. Many of our HF patients are critically ill and nearing the end of their lives, and we have seen inadequate enrollment in palliative care and hospice for these patients. Non integrated primary care physicians/cardiologists and the breakdown in communication in regards to discharge plans and follow up care.
Outcomes and Successes What are the key elements that will contribute to the success of your initiative? We have created a HF inpatient service to provide optimal diuretic management, medication regimens, length of stay and use of novel technology like CardioMEMS (pulmonary artery pressure monitoring system). We plan to follow patients closely in a longitudinal fashion via our HF Supportive Care Team. They will provide aggressive oral diuretic management and if needed IV diuretic management in the outpatient setting. We plan to integrate our palliative care services into the heart failure team, and will transition patients into palliative care or hospice when appropriate. What are the results? Too soon to determine. Our ambulatory HF Supportive Care Team began seeing patients in October 2015.
Future Steps What are your next steps? Weekly interdisciplinary team meetings to discuss challenges and issues. Virtual care resource center. What do you hope to achieve? Better coordination of care for patients. Better access. Better psychosocial support. Better end of life planning.
Lessons Learned Describe your lessons learned. In such a large health system, it s easy to lose track of what others are doing.
Questions Do you have any questions you would like to pose to the group? Are there any other health systems who are working on HF readmissions, using an ambulatory care management approach?