Transcript Cooperative Heart Failure Care

Cooperative Heart
Failure Care
Mary Allegra RN, MSN
VP, Strategic Clinical Development
Masonicare Home Health & Hospice
Rick Soucier, MD
Heart Failure Cardiologist
Hoffman Heart Institute Of CT
Mr. H
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78 Year old man with DM and HTN
Noticed gradual swelling in his ankles and 50 lb
wt gain in 6 months
SOB progressed- wheelchair bound
No CP, no obvious heart attack
Severe volume overload
Treated for 10 days at SFH
 Out of wheelchair, lost 40 lbs in 1 week
 “you saved my life”
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Mr. H II
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Back in 2 weeks after hospital discharge->
regained 32 lbs
Local fast food joint “your money’s no good
here”
Spent 1 month in house this time
Finally improved and went home
Questions
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What does he have?
What went wrong the first time? Why did it
happen again?
What can we do to improve this?
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.
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
Diet Noncompliance
24%
16%
Inappropriate Rx
Rx Noncompliance
24%
19%
Failure to Seek
Care
Vinson J Am Geriatr Soc 1990;38:1290-5
17%
Other
Heart Failure Pathophysiology
Myocardial injury
Fall in LV performance
Activation of RAAS, SNS, ET,
and others
Myocardial toxicity
Morbidity and mortality
-
ANP
BNP
Peripheral vasoconstriction
Hemodynamic alterations
Remodeling and
progressive
worsening of
LV function
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Heart failure
symptoms
Carvedilol Dose-Response Trial (MOCHA*): Effect
on Mortality and Morbidity in Systolic HF
Mortality†
Cardiovascular Hospitalizations
Mean number/subject
Mortality (%)
16
12
8
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§
0.4
0.3
0.2
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4
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0.1
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0
0
Placebo
6.25 mg bid 12.5 mg bid
25 mg bid
Carvedilol
Placebo
6.25 mg bid 12.5 mg bid
25 mg bid
Carvedilol
Patients receiving diuretics, ACE inhibitors, ± digoxin; follow-up 6 months; placebo (n=84), carvedilol (n=261).
*MOCHA, Multicenter Oral Carvedilol Heart Failure Assessment.
†Mortality
was not a planned endpoint in this study.
Adapted from Bristow et al. Circulation. 1996;94:2807-2816.
Issues to Consider in the Chronic
Heart Failure Patient
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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…..
Projected Mortality for Advanced Heart Failure
Exceeds Most Other Terminal Diseases
Mortality expectation % at One Year
90
80
70
60
50
40
30
20
10
0
AIDS
Data on file, Thoratec Corporation.
Leukemia
Lung Cancer
Pancreatic Cancer
Diagnosis
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.
End-stage Heart
Failure with Optimal
Medical
Management
Why Heart Failure?
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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
How can we make the system better
for chronic illness (Heart Failure)?
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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
Kaplan–Meier Time-to-Event Estimates for the Primary End Point — Readmission for Any
Reason or Death from Any Cause — and Each Component Separately, According to
Treatment Group
Chaudhry SI et al. N Engl J Med
2010;363:2301-2309
Saint Francis Hospital
Hartford, Connecticut
CHF Unit 2-2
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First hospital in CT to dedicate an inpatient unit to
CHF (20-bed unit)
CHF Clinic (1,000 patients/year) adjacent to unit
Collaborative interdisciplinary CHF daily rounds
Staff trained in “best practice standards” for heart
failure
Team: Heart Failure Cardiologist, Nurse Manager,
APRN, Cardiac Fellow , CHF Outpatient Coordinator,
Transition coordinator, Homecare nurses, cardiac
program manager
Masonicare Home Health &
Hospice
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Largest home care organization in the state of
Connecticut
2,500 patients cared for daily
8 branches
Part of the Masonicare continuum – LTC,
rehab, assisted living, independent living and
acute care.
Transition Program
Goal: Improve patient outcomes by reducing 30-day hospital re-admission rate for
Saint Francis Hospital/Masonicare CHF patients
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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
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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
Post Hospital Transition Plan
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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
Monthly meetings to drill down to cause of readmissions – Root cause analysis
Plan of Care
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Individualized protocols for
revisions to medication
profile with changes in
patient clinical status
RN implements medication
change orders for diuretic
therapy
Enhanced clinical monitoring
and physician
communication of patient
status changes
Initial Outcomes
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April 2009 – April 2010
111 CHF patients
30-day readmission rate 12%
(range 9% - 17%/quarter)
National & State average ~
25%
“Hot off the Press”
Percentage
Saint Francis Hospital & Masonicare Home Health
CHF Collaboration 30-Day Re-Admission Rates
30
25
20
15
10
5
0
National
Masonicare
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Time Frames
Data Collection
Results for 1 year – 4/1/2009 to 4/1/2010
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111 MCHH&H admissions (Primary diagnosis of
Heart Failure treated on Saint Francis Hospital CHF
unit 2.2)
Re-hospitalization rate for patients readmitted with any
diagnosis = 14 patients = 13%
Over one year re-hospitalization rate for patients
readmitted with diagnosis of Heart Failure = 7 patients
= 6%
Re-Admissions Analysis
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Leg infection
Exacerbation of symptoms - no daily monitoring
Social issues - lack of stable living arrangements and access to
food
Medication issues – dig toxicity
SOB – underwent thoracentesis
Inadequate payer source to support needs in home
What worked…. Create Sustainable
Links
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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
Transition Coordinator –
support/education provided to
patient/family