CONGESTIVE HEART FAILURE PROGRAM IN THE

RURAL SETTING JOHN RAYMOND MS, PA-C, MHP

A R GOULD HOSPITAL NORTHERN LIGHT HEALTH

NOVEMBER 7, 2019

Congestive Heart Failure

• Heart (or cardiac) failure is the state in

which the heart is unable to pump blood at a

rate commensurate with the requirements of

the tissues or can do so only from high

pressures

Braunwald 8th Edition, 2001

Heart Failure: A Progressive Disease, a Growing Burden

Prevalence 4.6 million Americans

Incidence 400,000 new cases/year

10 per 1000 population after age 65

Morbidity 870,000 hospitalizations (1995)

5% to 10% of all admissions

Most frequent cause of hospitalization in elderly

Mortality Causes or contributes to 260,000 deaths/year

Up to 70% of patients die suddenly

Cost $38.1 billion (hospitalizations 60% of cost)

Adapted from AHA Heart and Stroke Facts Statistical Update, 1999; Kannel and Belanger. 1991, Stevenson et al, 1993;

O’Connell and Bristow, 1994.

Projected Mortality for Advanced Heart Failure

Exceeds Most Other Terminal Diseases

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AIDS Leukemia Lung Cancer Pancreatic Cancer End-stage Heart

Failure with Optimal

Medical

Management

Diagnosis

Mo

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Data on file, Thoratec Corporation.

Rose EA, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J

Med. 2001 Nov 15;345(20):1435-43.

Types of Heart Failure

• Systolic (or squeezing) heart failure

– Decreased pumping function of the heart, which results in fluid back up in

the lungs and heart failure

• Diastolic (or relaxation) heart failure

– Involves a thickened and stiff heart muscle

– As a result, the heart does not fill with blood properly

– This results in fluid backup in the lungs and heart failure

Ventricular remodeling

CAD=coronary artery disease; LVH=left ventricular hypertrophy.

Risk Factors for Heart Failure

• Coronary artery

disease

• Hypertension (LVH)

• Valvular heart disease

• Alcoholism

• Infection (viral)

• Diabetes

• Congenital heart defects

• Other:

– Obesity

– Age

– Smoking

– High or low hematocrit level

– Obstructive Sleep Apnea

Congestive Heart Failure

• Symptoms:

– Shortness of breath

– Leg swelling (edema)

– Breathing worsens with lying flat (orthopnea)

– Fatigue

Classification of HF: Comparison

Between ACC/AHA HF Stage and

NYHA Functional Class

1Hunt SA et al. J Am Coll Cardiol. 2001;38:2101–2113.

2New York Heart Association/Little Brown and Company, 1964. Adapted from: Farrell MH et al. JAMA. 2002;287:890–897.

ACC/AHA HF Stage1 NYHA Functional Class2

A At high risk for heart failure but without

structural heart disease or symptoms

of heart failure (eg, patients with

hypertension or coronary artery disease)

B Structural heart disease but without

symptoms of heart failure

C Structural heart disease with prior or

current symptoms of heart failure

D Refractory heart failure requiring

specialized interventions

I Asymptomatic

II Symptomatic with moderate exertion

IV Symptomatic at rest

III Symptomatic with minimal exertion

None

Why Heart Failure?

• Patients are SICK

• A little medicine (or a small device) can go a long way

• Patients are under-recognized and under-treated

• Education goes a long way

Issues to Consider in the Chronic Heart Failure

Patient

• Disease of aging

• Multiple co-morbidities

• Typical patient on 15-20 drugs

• Common things are contraindicated: NSAIDs

• Energy levels, de-conditioning and exercise

• Dietary compliance and socioeconomics

• Disease literacy etc…..

Hospital Visits for Congestive Heart

Failure

Initial Episode

21%

Repeat Visit 79% Rates of readmission

• 2% within 2 days

• 25% within 1 month

• 50% within 6 months

Causes of Hospital Readmission for Congestive Heart Failure

17%

Other 19%

Failure to Seek

Care

16%

Inappropriate Rx

Rx Noncompliance

24%

Diet Noncompliance

24%

Vinson J Am Geriatr Soc 1990;38:1290-5

How can we make the system better for chronic

illness (Heart Failure)?

• Improve knowledge in the medical community (HFSA)

• Improve recognition prior to acute exacerbation

• Improve management of exacerbation (disease specific unit)

• Improve management of transitions (teach people after the bright lights are off)

• Improve (create) dialogue between hospital, home, and clinic

CHF is a Burden to our Patients and Community

• A Leading Cause of Readmission to AR Gould

• 30.1% at AR Gould versus national average 21.6%

• CMS Five-Star Quality Ratings Program

• $83,000 Readmission Penalty to AR Gould from Medicare in FY 2020

• The cost to Medicare is an average of $16,251 per admission

• Primary Care Physician Shortage in Aroostook County

• 46/100,000 versus state average of 67/100,000

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MISSION: TO DECREASE READMISSION RATES, CREATE EVIDENCE BASED, PROTOCOL DRIVEN CARE AND, INCREASE PATIENT QUALITY OF LIFE

Overview of the Performance

Improvement Effort

• CHF Clinic

• ACC/AHA Guidelines

• Organized Interdisciplinary Team

• Communication System

• Standard Educational Program

• “Bullet Proof” Handoff Process

• Follow patient after discharge

• Leverage Home Care Programs

• Continues to evolve to meet

patient need

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Transition Program Goal: Improve patient outcomes by reducing 30-day hospital re-admission rate for A R Gould Northern

Light Health CHF patients

• Promote a seamless continuum of care for CHF patients

• Establish an information sharing relationship between acute care & homecare

• Develop a homecare cardiac team with evidence based heart failure pathway

• Employ Transition Coordinator to “bridge the gap” between hospital and home

• Monitor outcomes and explore opportunities to improve performance

POST HOSPITAL TRANSITION PLAN

• Comprehensive assessment completed by specially trained Cardiac RN

• Individualized Plan of Care created based on patient needs

• Daily telehealth monitoring for specialty RN’s – phone calls to physician with variances to vital signs/weights, etc.

AMC Health/LifeLink Monitoring

ONE OF THE BEST DEVICES FOR MONITORING HEART FAILURE

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Post Hospital Transition Plan

• Interdisciplinary home health visits by cardiac home

health nurses, therapists, social workers, home health

aides and nutritionist as directed by physician.

• Dedicated line of communication to clinic through the

Nurse Navigator.

• Develop Infusion Clinic

• Continue to “Grow” Program to better serve Patients

Plan of Care

• Implements medication change

orders for diuretic therapy

• Enhanced clinical monitoring and

physician communication of patient

status changes through EMR

System

• Empower Patients in their health

care through education.

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Results

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CHF CLINIC

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Number of Readmissions

38% reduction in readmissions (37 →

23)

Only 6 of the 23 were

readmitted for a primary

diagnosis of CHF

CHF Clinic

What worked…. Create Sustainable Links

• Establishing relationships/trust across the

continuum

• Breaking down silos to provide information

sharing

• Efficient coordination of care as patient

transitions from one level of care to

another

• Homecare services with daily remote

monitoring

• Nurse Navigator – support/education

provided to patient/family

Contact Information

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