Best Practices in Managing
Patients with Heart Failure
Collaborative
July 7, 2016
Close to Home, Every Where
2
Our Local Community
Ambulatory
Locations
5
Acute care hospitals in
Crystal City, St. Louis, Troy,
Washington & Hermann*, MO
3
Specialty hospitals including
Children’s, Heart & Vascular
and Rehabilitation
3
13
256
Surgery Centers
Urgent Care Centers
Physician Practices
Medical Staff
& Co-workers
650
14,000
Physicians
Co-workers
including
Ministry Office
200
Advanced
Practitioners
Hospital
Utilization (FY14)
3
2.3 million
159,874
Office Visits
ED Visits
46,707
9,682
Surgeries
Births
*Affiliation with Hermann Area District Hospital. Note: Utilization is FY14 (does not include Mercy Lincoln)
Source: Mercy Finance and Mercy Locations Directory, April 2015
OP
Surgery
Center
Clinic
Urgent
Care
Affiliated
Hospital
Since we last spoke…
7/11/2016
4
Ambulatory HF Care Management Model:
New Ideas
•
Multi disciplinary team meets weekly to review readmissions on HF patients and
high risk HF patients in general the team is following.
– Cardiologists, PCPs, NPs, hospitalists, ED physician, palliative care physician, home health,
hospice, inpatient care management.
•
We have added an ambulatory chaplain to join our multi-disciplinary team to help
with spiritual and psychosocial needs
7/11/2016
5
Ambulatory HF Care Management Model:
New Ideas
•
•
Enrollment: Patients now being
enrolled in program at hospital
discharge by HF ambulatory nurse
care manager who sees them prior
to discharge
Discharge follow up: goal of our HF
team is to make sure that our
patients are seen more frequently in
first week after discharge by a
medical professional (home care,
CM, PCP, Specialist), to improve
transition to home.
7/11/2016
6
Ambulatory HF Care Management Model:
New Ideas
•
Patient Chart Advisory in Epic to communicate with others that the patient is being
seen by a HF ambulatory nurse care manager.
7/11/2016
7
Ambulatory HF Care Management Model:
New Ideas
• Epharmix: secure texting/telephonic system. Automated system set up to either call or send
secure text messages to patients to ask about vital signs and symptoms.
• Nurses are alerted if there is a significant weight change, BP, Heart rate or patient reported
symptoms of HF exacerbation
7/11/2016
8
Ambulatory HF Care
Management Model:
New Ideas
•
HomeIV lasix pilot started
June 2016
7/11/2016
9
CardioMEMS™ HF System
•
•
•
Implantable PA sensor wirelessly transmits data to cardiology office
Pilot began in December 2015.
To-date, Mercy Hospital St. Louis has placed 12 CardioMEMS ™ devices.
Pulmonary Artery
Pressure Sensor
Patient Electronics
System
7/11/2016
CardioMEMS™
HF System Website
10
Ambulatory HF Care Management Model:
New Ideas
•
•
ZOE® Fluid Status monitor: piloting use of noninvasive/external impedance monitors
in the home starting in July.
Cardiology will oversee the pilot.
7/11/2016
11
Ambulatory HF Care Management Model:
New Ideas
•
We are looking into partnering with our Virtual Care Center.
Naomi Coulter, 87, holds the iPad she uses to check in with her physician every morning. She credits
Mercy’s virtual home health program with helping her stay out of the hospital.
7/11/2016
12
Ambulatory HF Care Management Model:
Outcomes
Mercy Hospital St. Louis - HF Readmission Rates
1000
– Team of HF Supportive Nurse Care
Managers started October 2015.
– Currently managing 164 patients.
– Mercy Hospital St. Louis has had an
11.9% readmission rate in the 6
months of operation of the team
(Oct 2015 to Apr 2016).
18.90%
900
20.00%
18.00%
15.30%
800
13.20%
700
14.00%
600
12.00%
500
10.00%
400
8.00%
300
6.00%
200
4.00%
100
2.00%
0
CY2014
CY2015
January - April 2016
30-Day Readmission
154
136
48
Did Not Have a 30-Day Readmission
661
750
317
Total # of HF Inpatient Admissions
Percent
16.00%
815
886
365
18.90%
15.30%
13.20%
7/11/2016
0.00%
13
Ambulatory HF Care Management Model:
Outcomes
ACE/ARB
Beta Blocker
CY 2014
CY 2015
4/1/15 – 3/31/16
91.9%
90.8%
90.4%
1821/1982
2242/2469
2273/2515
71.7%
71.0%
72.0%
1611/2246
1987/2798
2058/2859
7/11/2016
14
Ambulatory HF Care Management Model:
Celebrating Accomplishments
•
Reducing readmissions: 7% decrease from baseline to initiation of our HF team in at
our main St Louis Hospital.
•
Referrals: More providers are becoming aware of our program and are referring
patients. Eg: palliative care
•
Our multidisciplinary team continues to meet weekly to review and discuss the plan
of care for high risk HF patients.
•
Improving relationships: We have developed a stronger relationship with inpatient
care management, home health and hospice.
•
Discharge Coordination: Integrated cardiologists & independent nephrologists have
developed a team approach at discharge.
7/11/2016
15
Ambulatory HF Care Management Model:
Celebrating Accomplishments
•
Case study: “Ruby”
7/11/2016
16
Ambulatory HF Care Management Model:
Improvement Interventions
•
•
•
Team is now seeing patients in the Mercy Jefferson Hospital area (March 2016)
Smaller hospital, more rural area with less resources.
Many have been set up with a home telemonitoring system for blood pressure, pulse
oximetry and weight.
7/11/2016
17
Ambulatory HF Care Management Model:
Challenges
•
Turnover of our HF ambulatory nurse care managers. This has impacted our ability
to see new referrals.
•
Difficulty communicating and collaborating with independent providers upon
hospital discharge.
•
Roadblocks with the implementation of our IV lasix protocol.
•
Difficulties with focusing our efforts within a large territory.
•
Turf issues with traditional Home Health care team.
7/11/2016
18
Ambulatory HF Care Management Model:
Next Steps
•
Implementation of external impedance monitors in the home (pilot starting in July).
•
Expansion of our in-home care management team to include a virtual care concept.
•
Developing a post acute care strategy of preferred skilled nursing facilities, for fragile
patients who need close coordination/follow-up with Mercy providers.
•
Evaluating the right size of the ambulatory HF nurse care management team. Future
growth/expansion?
•
Cost analysis of impact of the team.
7/11/2016
19
Ambulatory HF Care Management Model:
Lessons Learned
•
Having a multidisciplinary team that meets weekly to review complex patients is a
key to success.
•
It is important to have a high-level administrative steering team who monitors
results.
•
Nurses need to have a background in home-based care.
•
Innovative ideas are hard to implement quickly - especially in a big/complex
organization.
7/11/2016
20
Questions
•
What are your successes on keeping patients at home, using an IV lasix protocol?
•
Do any of you use impedance monitors in home or CardioMEMS?
•
Do any of the collaborative organizations use virtual care?
•
Does EMS assist with your heart failure patients? If yes, in what capacity?
7/11/2016
21