Transforming the Office Management of Heart Failure Using the Chronic Disease Model in a Family Medicine Residency Program Rhett Brown, M.D. Janice Huff, M.D. Eric Schneider, Pharm.D. Department of Family Medicine Carolinas Medical Center Charlotte, NC Carolinas HealthCare System

Acute Care Model Patient Initiated: “Doc, I am sick!” Brief Limited planning by the clinician Works well for the acute limited problem

Patient Initiated: “Doc, I am sick!”

Brief

Limited planning by the clinician

Works well for the acute limited problem

Current status of Chronic Illness Care in the U.S. 27% of hypertensives are adequately treated 29% and 26% of diabetics have well controlled lipid and blood pressure levels, respectively 35% of eligible patients with atrial fibrillation receive anticoagulation 25% of people with depression are receiving adequate treatment 50% of discharged CHF patients are readmitted within 90 days

27% of hypertensives are adequately treated

29% and 26% of diabetics have well controlled lipid and blood pressure levels, respectively

35% of eligible patients with atrial fibrillation receive anticoagulation

25% of people with depression are receiving adequate treatment

50% of discharged CHF patients are readmitted within 90 days

Chronic Illness 100 million persons in the US have at least 1 chronic illness 50 Million have more than 1 88% over age 65 have at least 1 chronic illness 22% over age 65 have 4 chronic illnesses

100 million persons in the US have at least 1 chronic illness

50 Million have more than 1

88% over age 65 have at least 1 chronic illness

22% over age 65 have 4 chronic illnesses

Quality Chasm Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards

Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care

Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards

System Change Concepts Why a Chronic Care Model? Emphasis on physician, not system, behavior Characteristics of successful interventions weren’t being categorized usefully Commonalities across chronic conditions unappreciated.

Emphasis on physician, not system, behavior

Characteristics of successful interventions weren’t being categorized usefully

Commonalities across chronic conditions unappreciated.

Knowledge versus Performance Physicians know how to treat chronic diseases They know what tests should be ordered and what medications should be prescribed What services are actually being provided fall far short of best practice standards We have a systems problem

Physicians know how to treat chronic diseases

They know what tests should be ordered and what medications should be prescribed

What services are actually being provided fall far short of best practice standards

We have a systems problem

The Watchword Systems are perfectly designed to get the results they achieve

Remember: We cannot work harder (systems are perfectly designed to get the results they achieve) We must work SMARTER! We must work as a TEAM! We must change OUR system

We cannot work harder (systems are perfectly designed to get the results they achieve)

We must work SMARTER!

We must work as a TEAM!

We must change OUR system

Chronic Care Model

Our Clinical Transformation Why HF Relatively small population Impact on our health care system is large Well defined and accepted guidelines Energy within our hospital system for improved outpatient management

Why HF

Relatively small population

Impact on our health care system is large

Well defined and accepted guidelines

Energy within our hospital system for improved outpatient management

Our Clinical Transformation Determine best practice benchmarks and work to decrease inter-physician variability Researched published data on best HF outpatient management system design Developed a concept for an improved healthcare delivery model

Determine best practice benchmarks and work to decrease inter-physician variability

Researched published data on best HF outpatient management system design

Developed a concept for an improved healthcare delivery model

Clinical Transformation Committee Administration Clinicians / Support staff Education Research Information Systems Nursing Pharmacy Community Resources Clinical Transformation Committee is multidisciplinary and meets monthly. Key members: Steering committee meets weekly to maintain momentum and monitor progress

Administration

Clinicians / Support staff

Education

Research

Information Systems

Nursing

Pharmacy

Community Resources

Clinical Transformation Committee is multidisciplinary and meets monthly.

Key members:

Steering committee meets weekly to maintain momentum and monitor progress

Registry Definition A computerized chronic disease registry is a computer application to collect and manage condition-specific data for a group of patients in order to support organized clinical care.

A computerized chronic disease registry is a computer application to collect and manage condition-specific data for a group of patients in order to support organized clinical care.

Critical Features of a Registry Identification of patients with a common illness Capture data elements electronically Real-time availability Searchable Linked to established guidelines Feedback to providers Enhance generation of letters to patients

Identification of patients with a common illness

Capture data elements electronically

Real-time availability

Searchable

Linked to established guidelines

Feedback to providers

Enhance generation of letters to patients

Registry Functions Patient Information entered into Registry Point of care data for patient visits Status reports provide clinician feedback Identify patients needing follow-up care

Why Use a Registry? Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards The registry is one way to narrow the chasm

Institute of Medicine report in 1999 described the “Quality Chasm” in delivery of health care

Institute of Medicine has proposed the redesign of primary care to close the quality chasm between current practices and optimal standards

The registry is one way to narrow the chasm

Why Use a Registry? Ensure regular follow-up Ensure use of evidence-based guidelines Provide reminders for clinicians (and patients) Facilitate planned care visits Monitor performance of practice team Enable population management Enable task delegation to team members … TO CHANGE SYSTEMS

Ensure regular follow-up

Ensure use of evidence-based guidelines

Provide reminders for clinicians (and patients)

Facilitate planned care visits

Monitor performance of practice team

Enable population management

Enable task delegation to team members

… TO CHANGE SYSTEMS

CVDEMS Flow Sheet

CVDEMS Visit Note

CVDEMS Visit Note

CVDEMS Visit Note

CVDEMS Flow Sheet

Services Needed/Recommendations

CVDEMS Decision Rules LDL Serum creatinine Serum potassium Aspirin therapy ACEI / ARB therapy Beta Blocker therapy Statin therapy Spironolactone therapy Hydralazine/Nitrate Coumadin in A Fib CTC Study Consent Assessment of LVEF ECHO Heart Failure Education Pharmacy Consult Pneumovax Influenza Vaccine

LDL

Serum creatinine

Serum potassium

Aspirin therapy

ACEI / ARB therapy

Beta Blocker therapy

Statin therapy

Spironolactone therapy

Hydralazine/Nitrate

Coumadin in A Fib

CTC Study Consent

Assessment of LVEF

ECHO

Heart Failure Education

Pharmacy Consult

Pneumovax

Influenza Vaccine

Decision Tools

Services Needed/Recommendations

Patient Goal Setting

Patient Goal Setting

Patient Goal Setting

Heart Failure Action Plan Analogous to an Asthma action plan Part of patient self management component

Analogous to an Asthma action plan

Part of patient self management component

Heart Failure Action Plan

Care Coordinator Adapted our current nurse triage positions Two RN Care Coordinators provide continuity Additional training in HF management Contact all HF patients after office visits Contact all patients on a regular schedule based on HF severity Follow standing orders for management of mild exacerbations

Adapted our current nurse triage positions

Two RN Care Coordinators provide continuity

Additional training in HF management

Contact all HF patients after office visits

Contact all patients on a regular schedule based on HF severity

Follow standing orders for management of mild exacerbations

Patient Support Group Initially held a patient focus group From focus group recommendations developed Monthly support group HF disease education Opportunity for residents to participate in patient education and facilitating a group

Initially held a patient focus group

From focus group recommendations developed

Monthly support group

HF disease education

Opportunity for residents to participate in patient education and facilitating a group

Measure Outcomes Hospitalization rates Quality of life scores Medication refill compliance

Hospitalization rates

Quality of life scores

Medication refill compliance

Lessons Learned Difficulty and time required to navigate the IRB and RRC process Communicating and achieving ‘buy-in’ when working with part-time providers Cultural change takes TIME and PERSERVERANCE Awareness of subcultures within our office

Difficulty and time required to navigate the IRB and RRC process

Communicating and achieving ‘buy-in’ when working with part-time providers

Cultural change takes TIME and PERSERVERANCE

Awareness of subcultures within our office

“ Well, I do have this recurring dream that one day I might see some results.”