Essentia Health. Heart Failure and Remote Monitoring. Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager

Essentia Health Heart Failure and Remote Monitoring Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager

Essentia Health Oct 2014 No reproduction without permission

Why Heart Failure? Prevalence Affects 5.8 million in the U.S. Over 650,000 new patients annually The lifetime risk of developing HF is 20% for Americans 40 years of age. HF is the most frequent cause of hospitalization in elderly (> 65 y/o) Prognosis 1/2 of people who develop HF die within 5 years of their diagnosis Less than 25% are alive at 10 years

Heart Failure Progression is Inevitable Population of the US is aging Survival rates has improved HF is not always treated correctly Patients do not adhere to diet and medication regime Projections show the prevalence of HF will increase 46% from 2012 to 2030, resulting in >8 million people 18 years of age with HF AHA Heart Disease & Stroke Statistics 2014 Update

Conventional HF Care Nurtures a Cycle of Acute Care Dependency Failure to recognize early symptoms, neglects to seek timely help Clinic Management outside of HF clinic maybe be incomplete relative to HF patients complex needs Hospital stay may not be sufficient to find best medical regimen & educate patient. Lack of preparedness increases odds of early readmission. Hospital Patient decompensates and requires hospitalization

Interesting Comparisons Deaths per year Research Dollars in Millions Heart Failure Lung Cancer Breast Cancer Heart Failure Lung Cancer Breast Cancer HF: 282,800 deaths/year Lung Cancer : 64,475 Breast Cancer: 41,737 HF: $28.7 million Lung Cancer : $285 million Breast Cancer: $559 million

What will it Cost? Estimated lifetime cost per each individual HF patient is $110,000/year In 2012, total cost for HF was estimated to be $30.7 million Projections show that by 2030, the total cost of HF will increase almost 127% to $69.7 billion from 2012

Current Fee for Service world More we do, the more we are paid

We like our patients sick! Sicker the patients more tests, ER visits, surgeries, admissions, readmissions. $$$$$

So What? Why do we have to change We re happy just the way it is. Well times are a changing!

Essentia Health as an ACO One of six health care systems in Country to achieve: NCQA Accreditation as an Accountable Care Organization Definition A provider-based organization that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs. (Triple Aim)

PROGRAM STAFF Medical Director Cardiologist oversight of program, clinical leadership Cardiologists Essentia s HF Program 1998 Duluth Only 1 CNP 1 RN 1 CMA Accurate diagnosis and treatment plan Essentia s HF Program Today Virginia 2 NPs, 2 RNs Spooner/Hayward 1 PA & 1 NP, 2 RNs Ashland 1 NP, 1 RN Duluth (Main hub) 1 PA, 4 NPs, 4 RNs Superior (Staff from Main) Fargo 1 NP & recruiting another,2 RNs Brainerd 2 NPs & several RN s who float

Essentia Health HF Program Sites HF Program Site Outreach Site

Essentia s HF Program Model Consult 5-7 days after hospital discharge Patients managed by APP in ambulatory setting Seen by cardiologist initially, annually and as needed Registered nurses provide continuous case management: Phone triage Follow-up on labs/ test results Utilize protocols Manage telescale data ONGOING PATIENT EDUCATION

PROGRAM DYNAMICS Patient and Family Centered Care - Goals Multidisciplinary team approach to care Continuity of care Coaching and support Education Immediate feedback on health choices Relationship building with patient/family Engaged/passionate staff

Referrals to HF Program Admission for HF in last 6 months or a HF exacerbation treated as outpatient in last 6 months Newly diagnosed cardiomyopathy Any patient with CRT (special pacemaker for HF patients) Patient requiring increased doses of diuretics to manage volume Any heart failure patient needing extra education, support, close management High risk (HFSA criteria) multiple co-morbidities: Renal insufficiency, Low output state, DM, COPD, NYHA III or IV, Frequent hospitalization for any cause, Cognitive impairment, History of depression, Inadequate social support, Poor health literacy, and Persistent non-adherence to therapy Patient agrees to plan

SHOW ME THE MONEY!!

Piloting a Heart Failure Program Pilot of 25 patients in 2000 This pilot revealed: 82% Reduction in HF hospitalizations 81% Decrease in Length of Stay 88% Decrease in ER Visits

Second Pilot with Payer BCBS of MN 29 patients in 2002 Type of Care Pre- Program 6 months Post- Program 6 months Percent Change Inpatient $1,149,080 $185,134-84% Outpatient $124,884 $125,498 0% ER $379,852 $66,318-83% Prof. Fees $674,428 $706,298 5% Lab/Radiol $138,781 $118,064-15% Pharmacy $124,229 $137,312 11% Total $2,591,254 $1,338,624-48% Savings of $1.25 Million

6 Month Readmission Rate for HF 40 40 40 40 40 40 18.1 6.6 20 18 11 10.9 10.9 2.8 3.1 3.5 4.8 2.9 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10 National Average St. Mary's HF Program Telescale (<1%)

30 Day Hospital Readmissions 30.6 25 25 25 21.2 15.2 5 4.5 7.6 National St. Mary s HF Program 2010 2011 2012

2014 YEAR END SUMMARY HF Program Patients 2,288 HF Admissions (209) 9.1% All Cause 30 Day Readmissions (34) 16.3% HF 30 Day Readmissions (10) 4.8%

Appropriate use of telescales Consider for: Patients with 2 or more hospitalizations for HF during the past year Patients unable to self-report weights within given parameters and/or inadequate social support Patients who live great distances from clinic and have difficulty getting to office visits Not recommended for: Dialysis patients Weight loss program Patients residing in skilled nursing facility with 24 hour care Unsteady patients

30 day Re-admission for HF Yearly HF Admission Rate # of Patients on scales 277 290 296 185 177 183 203 12.4 12.3 2008 2009 0 2010 7.1 5.9 11.9 0 2.8 2011 2012 0 2013 6 0 2014 6

Advantages to Tele-monitoring Facilitates early intervention and prevents ER visits and hospitalizations Improved patient adherence with care plan Patients get immediate feedback on life style choices High patient satisfaction Family reassured Provides additional opportunity to educate patients Builds trust between patient and provider

Monitoring and Exception Review Patient alerts in Cardiocom Nurse reviews data in both Cardiocom and EPIC Makes decision if patient needs to be contacted If assessment is needed the nurse considers the following: Nursing assessment and education needs Review medication list Dietary compliance Follows diuretic protocol as indicated/or talks with provider Initiate office visits or primary care referrals as needed Care plan monitoring; hospitalization initiation Communication with team members (other specialties)

Tele-monitoring Exception Review RN calls patient and assesses the following: Nursing Assessment Medication list reviewed Dietary Compliance Educational needs Follows Diuretic protocol as indicated/or talks with NP/PA Makes follow-up recommendations Initiate office visits or primary care referrals Care Plan monitoring; Hospitalization initiation Communication with team member (other specialties)

THEN Fee for Service Model Expense Center HF Program NOW ACO model Greatly improves the quality of care for HF patients Little if any payment for services Reimbursement reducer Prevents admissions, readmissions and ED visits Reduces the cost of medical care by reducing admissions, readmissions and ED visits Improved service and experience for patients with close monitoring and coordination of care ACOs rewarded for improving quality of care and controlling costs.

Growth of HF Program Added Telehealth video visits to remote sites Opened additional HF Program sites Integrated home scale data into electronic medical records Cross coverages options with other sites Advance Care Planning Pilot Program

Vision for Essentia Health HF Program Be more involved with hospitalized HF patients Seamless interface with primary care Patients hospitalized with a primary diagnosis of heart failure will be enrolled in the heart failure program Tele-health available at all sites for timely access Major contribution to the ACO model and continue to meet the triple aim; Quality/Cost/Service Expand Advance Care Planning

I ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. Maya Angelou

Thank you!! Questions?? Denise Buxbaum, RN, BSN, CHFN Heart Failure Program Manager Essentia Health Heart & Vascular Center 407 East Third Street Duluth, MN 55805 P 218-786-4714 F 218-720-4633 Denise.Buxbaum@EssentiaHealth.org