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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
Business Plan: Congestive Heart Failure Outpatient Services Clinic
Simonette P. Elgert
Siena Heights University
LDR 609- Health Care Systems Management
October 29, 2013
Dr. John Fick
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
CONGESTIVE HEART FAILURE OUTPATIENT SERVICESA BUSINESS PLAN OUTLINE
Today in the United States chronic disease is the major cause of disability, is the main reason
why people seek health care, and consumes 70% of healthcare spending. With chronic disease,
the patient’s life is irreversibly changed. Neither the disease nor its consequences are static. They
interact to create illness patterns requiring continuous and complex management. Furthermore,
variations in patterns of illness and treatments with uncertain outcomes create uncertainty about
prognosis. The key to effective management is understanding the different trends in the illness
patterns and their pace. The goal is not cure but maintenance of pleasurable and independent
living (Holman & Lorig, 2000).
Executive Summary
Congestive Heart Failure (CHF) is a chronic disease caused by the inability of the heart
to pump enough blood and oxygen to support other organs. According to Centers for Disease
Control and Prevention (CDC), there are around 5.7 million people in the United States who
have heart failure. It is the cause of more than 55,000 deaths per year and the contributing cause
in more than 280,000 deaths (1 in 9) in 2008. CHF costs the nation 34.4 billion each year
including the cost of health services, medications and lost of productivity. Early diagnosis and
treatment can improve quality of life and life expectancy. Treatment usually involves taking
medications, reducing salt in the diet and getting daily physical activity (www.cdc.gov).
The number of persons with chronic illness is growing at an astonishing rate due in part,
to the aging of the population, lifestyle habits, such as increased incidence of obesity, and the
greater longevity of persons with many chronic conditions. Heart disease is the number one
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
cause of death in Michigan accounting for 23,044 deaths and 2,346 deaths in the city of Detroit
alone in 2010 (www.mdch.state.mi.us). Although heart failure is a serious condition that
progressively worsens overtime, there are a number of treatments that can relieve symptoms and
stop or slow the gradual worsening of the condition. The goals of the therapy are:
a. Relieve symptoms and improve quality of life
b. Slow the disease progression
c. Reduce the need for emergency room visits and hospitalization
d. Help people live longer
It is the intent of this business plan proposal to contribute to the goals of therapy for
patients with Congestive Heart Failure (CHF) through the provision of patient-centered approach
to heart failure care, continuity of care post hospitalization and most importantly, care
coordination in an outpatient setting. It is also the goal of CHF Outpatient Services Clinic to
decrease hospital readmission, decrease cost per case and improve the quality of care and
satisfaction for this patient population.
Proposal
Congestive Heart Failure Outpatient Services Clinic will operate within the outpatient
department of the hospital and will service patients diagnosed with heart failure. Criteria for
admission into the clinic include but are not limited to: left ventricular ejection fraction (LVEF)
of <40%, New York Heart Association (NYHA) class II-IV as determined by multigated
acquisition scan, more than one hospital readmission in the past year with heart failure (Henrick,
2001). Referrals will come from the physicians, nurses and or patients. As stated above, the
goals of treatment for heart failure are symptom management, treatment of the underlying
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
causes, lifestyle changes and medications. The identified patients will be assisted in most aspects
of treatments in order to manage symptoms and reach the goal of slowing the disease progression
and decrease hospital admissions/readmissions. The Heart Failure Society of America (HFSA)
proposed guidelines will be used as the clinic workflow consisting of the following components:
a. Disease Management – which will include comprehensive education and
counseling on self-care, financial support, and availability of resources.
b. Functional Assessments – will utilize New York heart Association (NYHA) Class
Function status assessment on every visit, 6-minute walk test (6MWT) on
baseline and during risks assessments, Cardiopulmonary exercise testing to set a
baseline.
c. Quality of Life Assessments – will be completed and documented at baseline and
status change to include symptoms assessment and health related quality of life.
d. Medication Therapy and Drug Evaluation – will include medical therapy that
follows established HF medication guidelines such as Angiotensive converting
enzyme (ACE) inhibitors, beta blockers, diuretics, potassium and magnesium
supplements, digoxin and other anti-arrhythmic drugs.
e. Device Evaluation – will include a process to evaluate and document devices such
as ICDs, care coordination with electrophysiologists and a system in place to
address alerts and recalls of devices.
f. Nutritional Assessment – will include nutritional assessment and education by a
dietician focusing on those patients with co-morbidities and tracking of nutrition
metrics such as weight and body mass index.
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
g. Follow- up – standardized follow-up appointment within 7-10 days at the clinic
post hospitalization; preferably after being seen by the cardiologists. Maintenance
visits monthly.
h. Advance Planning – include assistance for patient to determine both medical and
non-medical care the patient will receive before the condition preclude them from
making decisions.
i. Communication – provision of open communication between patient and
provider.
j. Provider Education – will include mechanisms to track and ensure provider
competencies are up-to-date.
k. Quality Assessment – will be measured through outcomes (readmission rates,
survival rates), processes (weight tracking, patient education) and structural
components (registries and reporting to regulatory bodies)
(www.nursingeconomics.net).
A cardiology Nurse Practitioner (NP) or a Clinical Nurse Specialist (CNS) will be the
primary care provider under the supervision and in consultation with the chief of
cardiology. Aside from the NP/CNS and physician, other members of the team will
include:
a. Registered Nurse – will assist the NP with assessment and providing education.
b. Dietician – will assist with nutritional needs and education.
c. Social Worker – will assist with social needs affecting ability to care for self or
follow treatment regimen.
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
d. Patient Care Technician – will assist with vital signs monitoring, exercise or
phlebotomy.
e. Unit Clerk – will assist with appointments, scheduling and coordination with
other physicians
The proposed site is the currently vacant Rapid Admission Unit (RAU) located on
the West side of the hospital on the first floor. The clinic will operate 5 days a
week, Monday to Friday between the hours of 8:00 am to 4 pm not including
holidays. Patient visits will vary ranging from 1-2 times a week or every 6 months
depending on how managed the patients symptoms are.
Market Analysis
Heart failure patients are of Medicare age. It occurs most frequently in those over
age 60 (www.hopkinsmedicine.org). But the services that will be provided by the heart failure
clinic will be available to any patients who meet criteria for admission to the clinic regardless of
age, gender and racial origin. The service areas will be consistent with the hospital’s defined
radius of service. The clinic will be available to patients in the tri-county areas of Wayne,
Oakland and Macomb and within the 20-mile radius from zip code 48236. The availability of the
clinic services will be marketed to all the physicians and hospitalists for possible referrals. The
referrals may be initiated by any physicians, doctors offices, case managers and ER staff. The
clinic is accessible through the west entrance of the hospital and is on the first floor.
The greatest opportunity for this service will be for those patients who are
discharged from the hospital with a heart failure diagnosis. The discharge planner will be
responsible to make the referral and secure an appointment prior to the patient’s departure by
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
contacting the clinic. Appointments will be made within 7-14 days preferably after the patient
has been seem by the cardiologists. The clinic NP/CNS will follow up with the patient and
coordinate with the home health care agency responsible for the care of the patient post
hospitalization. The heart failure clinic will support the needs of the patient population suffering
from this condition. Although there is no cure for heart failure, it is possible for patients to enjoy
better health with disease management, which will be provided by the heart failure clinic. The
goal is to keep the patients from having to be admitted as a result of increased symptoms related
to poor compliance with treatment. After much research and review of the requirements for
Certificate of Need (CON) through The Michigan Certificate of Need Program published in 2005
by the Citizens Research Council of Michigan, the proposed heart failure clinic does not require
one. The clinic is considered an extension of the hospital’s outpatients services and Clinical
Decision Unit (CDU).
After extensive research of the services our immediate competitors (Henry Ford,
Beaumont) provide through their websites, both do not offer the same services as proposed.
However, the John D. Dingell VA Medical Center, located on 4646 John R. Street, Detroit
Michigan 48201, about 10.28 miles from the St. John Hospital and Medical Center has two heart
failure clinics which are run in conjunction with a pharmacy-drug titration clinic. Their clinic
provides care for newly diagnosed CHF patients, those with recent hospitalization with CHF as
the primary diagnosis or those with frequent CHF admissions (www.detroit.va.gov). VA
Hospital is not considered a competition to the proposed clinic. Their health care services are
limited to the veterans and military service members.
There is very low to no risk involved in this proposed heart failure clinic. Studies
have shown that on a small scale, NP/CNS-run clinic for heart failure has demonstrated positive
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
outcomes in the management of these patients. In the very near future advanced practice nurses
will become primary care providers (Henrick, 2001). As the era of Accountable Care
Organizations (ACOs) is ushered in and many provisions of the Affordable Care Act (ACA)
begin to be implemented, nurses will play a fundamental role in the transformation of the
healthcare system. The changes in nursing will enhance the success in an increasingly
competitive and financially difficult environment (Rowe, 2013). Advanced practice nurses play
an important role in the treatment of heart failure through their education, nurses approach these
patients holistically and integrates many aspects of care (Henrick, 2001).
Presence in the market requires that services be positioned vis-à-vis competing
services. Positioning depends upon the strengths and weaknesses of the organization and the
issues in the external environment (Swayne, Duncan & Ginter, 2008, p. 279). For the proposed
clinic, the appropriate positioning strategy is cost leadership, which uses services that are simple
to produce (p. 281). The market entry strategy appropriate for this plan is internal venture
strategy, which is the establishment of an independent entity within an organization to develop
products or services (p. 228). This strategy allows the use of existing resources, which is how the
clinic will be designed. In order to gain success, the support of the physicians and staff to the
program are critical.
Internal Assessment
The St. John Providence Health System Strategic Focus are:
a. Patient Experience
b. Strategic Market Growth
c. Value Demonstration
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
d. Associates/Physicians Engagement
e. Defined Population Management
The proposed heart failure clinic is in alignment with the defined population management
strategy. The target of this proposal is the CHF patient population disease management and the
goal is to decrease readmission rate, cost of care and improve quality of care and satisfaction.
Nursing, in partnership with the chief of cardiology will own the implementation of the
proposal. The sponsoring department’s strategies include:
a. Spiritually Centered Holistic Care
b. Improved Patient Experience
c. Patient Safety and Quality
d. Clinical Ladder
e. Shared Governance
f. Research
g. Magnet Pathway Journey
The concept of the heart failure clinic is in alignment with patient safety and quality, patient
experience and research. The plan is to gather data relating to how the clinic will help
improve disease progression and symptom management as evidenced by decreased
readmission rate of the heart failure patient population.
There is currently a process in place that is similar to this proposal at St. John Hospital
and Medical Center. Twice a week, there is a physician who comes in and sees patients
referred by the NPs. There is no formal process in place and there is no defined goal/purpose.
There is also no data gathering or tracking mechanism that could be used for data
management. The lead NP for cardiology is hoping to have a formalized heart failure clinic
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
to support their efforts in trying to educate patients regarding care management post
hospitalization. In the meantime, education starts and ends in the hospital setting.
Heart Failure patients are usually referred to home care post discharge. The services that
they offer are limited and sometimes lacking due to visit restrictions. It is the hope that the
proposed heart failure clinic will bridge the gap in care in the outpatient setting.
St. John Hospital and Medical Center is well positioned to develop this service. First,
there is already an existing structure that would house the clinic. The location of the proposed
clinic is on the first floor adjacent to the emergency room and close to the clinical decision
unit (CDU). It is also close to a main entrance and parking structure. Second, there are
already potential candidates for the nurse practitioner, someone dedicated to the care of heart
failure patients. The organization also has the means of supporting the clinic through grant
money received from donors. There was a recent donation of four million dollars towards
cardiology projects. According to the chief of cardiology, the two hundred thousand dollars
interest yearly will be used to fund different cardiology initiatives. If the program is
successful in meeting its goals, a recommendation will be made to make this proposal
system-wide.
As mentioned earlier, nursing will take the lead on this proposal in collaboration with the
mid-level providers and the chief of cardiology. This will be an NP-run clinic, under the
direction of Dr. Lalonde. There will be a director sponsor, most likely, Laura Cadieux, since
she is over the cardiology division. The other team members will include a registered nurse,
dietician, a social worker/case manager, patient care technician and unit clerk. This proposal
will also be assigned a manager sponsor who will ultimately be responsible on the day-to-day
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
operation of the clinic. Since the lead NP will focus on this project, the other mid-level
providers will have to cover some inpatients during rounding.
Below is an illustration of the proposed heart failure clinic workflow:
Patient Referral
Unit Clerk Nurse Practitioner
Readmission
Telephone follow-up
Education Referral
RN Clinic Admission SW
Symptom/Disease Management
Regular Follow -up
Non-compliance Goals achieved
Financial Analysis
As hospitals are faced with the relentless shift toward caring for only the
most acutely ill patients, organizations will be forced to develop more efficient,
efficacious, cost-minimizing, and evidenced based treatment paths in order to remain
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
viable and competitive in the rapidly changing healthcare marketplace (Sieck, n.d.).
The proposed heart failure clinic is in response to the need of the organization to
manage chronic diseases and to decrease readmission rate. The demand for this kind
of service will increase from referrals due to high number of heart failure patients
who have multiple admissions due to poor symptom management. The higher volume
of patients seen in the clinic could reduce the amount of hospital admission.
The proposed physical location of the clinic is the vacant rapid admission unit.
The space set-up is usable and is appropriate for a clinic setting. It has a nursing
station, semi-private patient rooms, restroom facilities for both patients and staff and
conference room . There is ample space for a good weighing scale and an exercise
machine for assessment of endurance and tolerance to exercise. The amount of
renovation that will be required in order to make it functional is minimal. It will need
painting, scrubbing and re-arranging of furniture and hospital beds. It is already
equipped with a telephone line and a computer.
E-care will be used as source of patient information and admission history as well
as laboratory tests and other imaging results such as X-ray and CT scan. In the current
system, any patient encounters are added and reflected in our electronic medical
record (EMR), including outpatient tests. The clinic will follow the same path. There
will be a need to add the CHF clinic to our current list of service areas and possibly
add specific identifiers to the registration number. No major information technology
changes or upgrades have to occur. Aside from dedicating its own staff to the new
clinic and purchasing some equipment (weighing scale, exercise machine, copier, fax
machine) and adding two additional computer terminals or portable devices such as
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
an I-Pad, there will be no major resources needed in order to become operational.
There will be no pricing strategy that will be pursued. The services that will be
provided in this clinic will be compensated as part of values-based purchasing as set
forth by the different payers. Below is the Financial Assumption for the proposed
CHF Clinic.
Assumptions
Volume Assumptions 1,300 (based on 2012 FYTD CHF Admissions
Hours of Operation Monday – Friday8:00 am – 4:00 pmexcluding holidays
Revenue/Case Dependent on Medicare payments. If the hospital readmission rate is decreased, 1-2% of penalty will be avoided (see below explanation)
Start-up Expense $5,000 – site renovation$10,000 – equipment purchase expense including I.T.
Staffing/FTE Job Class:Nurse Practitioner – 1.0 FTERegistered Nurse – 1.0 FTEPatient Care Technician – 1.0 FTE (phlebotomy trained)Unit Clerk – 1.0 FTEDietician – 0.0 FTE (rotation)Social Worker – 0.0 FTE (rotation)
Rate of Pay (entry level) Job Class:Nurse Practitioner – $35/hourRegistered Nurse – $28/ hourPatient Care Technician – $13/ hourUnit Clerk – $11/ hourDietician – $18/hourSocial Worker - $14/hour
Other Operating Expense TBD
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
The true revenue that will be realized in this proposal will be in the form of cost
savings and higher reimbursement to the hospital. First, indirect savings will be
obtained from saved bed days and reduction of aggressive treatment (if readmission is
avoided). Second, it will be in the form of no dollars lost. The average reimbursement
is $5759, which often does not receive sufficient reimbursement to cover the costs of
care for the CHF patient. The financial break-even point for CHF is about 5 days but
the average length of stay is greater than 5 days. The average dollars lost is
approximately $2104 per patient (Sieck, n.d.). With the new Patient Protection and
Affordable Care Act (PPACA) legislation, hospitals are vulnerable to more losses.
They could become fully financially responsible for the care of such patients (Sieck,
n.d.). The goal of the proposed CHF clinic is to avoid those losses.
Implementation Plan
In order to have sufficient time to completely plan the specifics of this
proposal, and to not compete with some major undertakings that are going to take place in
the next 2-4 months. The proposed implementation date is April 7, 2014. The following
timeline will be followed:
Business Plan: Congestive Heart Failure Clinic
Primary Sponsors: Dr. Thomas Lalonde, Chief of Cardiology Laura Cadieux, Director of Nursing, Cardiology Division
Members: Mary Jo Pitera, Lead Cardiology Nurse Practitioner Simonette Elgert, Clinical Nursing Manager, 4 North Appointee from Social Work/Case Management Appointee from Nutritional Services Appointee from Registration/Outpatient Services Jim Wild, Maintenance and Engineering Appointee from Finance
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
Dave Poynter, Information Technology
Optional: Tomasine Marx, V.P. of Finance Board Member Representative Donor Representative Additional Cardiologist Representative Lead Director Clinical Decision Unit Manager Quality Department
Date/Time What Who Where
November 2013 Initial Meeting withSponsors and
members; Appointment of representatives; division of labor
along with timelines
Sponsors andAll Members
Cardiac Cath Lab Conference Room
November 2013Meeting with Jim Wild in order to
discuss specifics of needed site
updates/Meeting with IT
SponsorsJim Wild
Simonette ElgertMary Jo PiteraDave Poynter
Cardiac Cath LabConference Room
December 2013 Workflow Meeting/Finance Considerations
SponsorsAll Members
Cardiac Cath Lab Conference Room
January 2014(will meet every 2
weeks)
Creation of Policies and Procedures;
Purchase of Equipment
All Members Cardiac Cath Lab Conference Room
February 2014(will meet every 2
weeks)
Appointment of Staff/Hiring;
Finalization of Process
SponsorsAll Members
Cardiac Cath Lab Conference Room
March 2014(will meet weekly)
Meeting with Finance and Registration for
finalization of processes;
SponsorsAll Members
Cardiac Cath Lab Conference Room
April 2014 Go Live SponsorsAll Members
CHF ClinicConference Room
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
The objective of the proposed CHF clinic is to serve patients diagnosed with heart
failure, to assist them towards slowing down the disease progression. The goal is to
decrease the overall readmission rate by symptom management, education, counseling
and follow-up. In 2012, St. John Hospital and Medical Center admitted 1,294 patients
with CHF as the principal diagnosis. 6.41% of those patients were readmitted to the
hospital within 15 days of discharge and 11.05% were readmitted within 30 days of
discharge (Juchartz, 2013). The goal is to decrease both rates by at least 5% in the first
year and 10% in the subsequent years. The workflow and progress will be monitored
closely. Opportunities for improvement will be identified. The first few days will be
critical. The team will come together after the first week and will find ways to improve
on some of processes breakdown. Re-appointment of tasks may be necessary. Progress
report will be made available to the sponsors and to all members of the team. Regular
meetings will be called until the workflow is smoothen out. Data collection will start
immediately and measures will be monitored by the Quality Department for Clinical
Excellence reporting.
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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES
References
Centers for Disease Control and Prevention. (2013, July 26). Heart Failure Fact Sheet. Retrieved
from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm
Citizens Research Council of Michigan (2005). The Michigan Certificate of Need Program.
Retrieved from http://www.crcmich.org/PUBLICAT/2000s/2005/rpt338.pdf
Heart and Vascular Institute. (n.d.). Congestive Heart Failure. Retrieved from
http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/
conditions/congestive_heart_failure.html
Henrick, A. (2001). Cost-effective outpatient management of persons with heart failure.
Progress in Cardiovascular Nursing, 16(2). Retrieved from
http://www.medscape.com/viewarticle/407751_2
Hines, P., Yu, K., Randall, M. (2010, March-April). Preventing heart failure readmissions: is
your organization prepared?. Nursing Economics, 28(2). Retrieved from
http://www.nursingeconomics.net/ce/2012/article28074074.pdf
Hodge, T. (2002, April 18). Improving chronic disease management: a powerful business case
for congestive heart failure. Retrieved from http://
www.health.gov.bc.ca/library/publications/year/2002/congestive_plan.pdf
Holman, H., Lorig, K. (2000, February 26). Patients as partners in managing chronic disease.
BMJ, 320(7234), 526-527.
Juchartz, S. (2013). Clinical excellence reporting. (E-mailed report). Accessed on 2013,
September.
Longest Jr, B. B., & Darr, K. (2008). Managing health service organizations and systems (5th
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