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  • 1. Catholic Healthcare Partners’ Closing the “GAP” for Heart Failure Don Casey MD, MPH, MBA, FACP* Chief Medical Officer and Principal Investigator Catholic Health Partners (Cincinnati, OH) June 28, 2006 *Currently Vice President, Quality & Chief Medical Officer Atlantic Health, Morristown, NJ
  • 2.  
  • 3. Catholic Healthcare Partners Toledo Lorain Lima Springfield Cincinnati Kentucky/Indiana Tennessee Northeast PA Youngstown/Warren No. Kentucky
    • 10 Regional Health Systems – Emphasizes the local community and promotes integrated continuum of care
    • System Office - Provides oversight and select centralized services.
    • 31 Hospitals
    • 16 Long-Term Care/Nursing Homes
    • 19 Elderly Housing
    • 10 Home Health Agencies
    • 5 Cancer Centers
    • 8 Freestanding Outpatient Surgery Centers
  • 4.  
  • 5.  
  • 6.  
  • 7.  
  • 8. Priority areas for quality improvement addressed by the CHP HF-GAP project
    • Care coordination
    • Self-management/Health literacy
    • End of Life with advanced organ system failure
    • Frailty associated with old age
    • Ischemic heart disease
    • Major depression
    • Medication management
    • Stroke
    • Tobacco dependence treatment in adults
    From: Priority Areas for National Action: Transforming Health Care Quality (2003) ( IOM )
  • 9. Strategic Goals for CHP HF GAP
    • Effective and lasting influences of expertise and energy of Partnership (including AHRQ) and its members upon the CHP system and its local regions
    • Organizational alignment of quality improvement initiatives, including senior management and governance understanding, acceptance, leadership and incentives
    • More effective care coordination post-hospital discharge, including end-of-life care
    • Enhanced cooperation and collaboration with physicians, especially with quality improvement efforts
    • Enhanced internal and external financial and non-financial incentives, especially “Pay for Performance”
  • 10.  
  • 11. Components of Successful Healthcare Delivery Models for Heart Failure
    • Physician-directed care with assistance from nurse coordinators in patient management or nurse-managed care by experienced advanced practice cardiovascular nurses with access to a cardiologist for consultation
    • Intensive, comprehensive patient and family/caregiver education about heart failure with an emphasis on a low-salt diet, medications, symptoms that signal worsening heart failure, weighing, and management strategies for problems
    • Vigilant, frequent follow-up after hospital discharge
    • Optimization of medical therapy (ensuring patients are prescribed the appropriate drugs in appropriate doses) with published guidelines based on large-scale randomized, controlled clinical trials
    • Information systems that support effective point-of-care evidence-based clinical decision making (e.g. registries, patient records, laboratory information, prompts and reminders, self-management tools, etc.)
  • 12. Components of Successful Healthcare Delivery Models for Heart Failure (Part II)
    • Increased access to healthcare professionals for problems by telephone or “walk-in” appointment
    • Early attention to signs and symptoms of fluid overload (ie, flexible diuretic regimen)
    • Supplementation of in-hospital education with outpatient education
    • Coordination with home health agencies where appropriate
    • Attention to behavioral strategies to increase compliance
    • Emphasis on addressing personal, financial, and social barriers to compliance
    • Assessment and assistance in management of social and financial concerns
    • Adaptable to communities without academic medical centers
    • Cost-effective and clinically relevant performance measurement systems
  • 13. Co-investigators
    • Don Casey (CHP CMO)
    • Margie Namie (CHP QMT)
    • William Abraham (National HF Expert)
    • Lynn Barrow (CHP CPOE/Clinical IT)
    • Ileana Pi ñ a (National HF Expert)
    • Rick Snow (Quality Improvement Expert)
    • John Schaeffer (Cardiologist Leader)
    • Rich Glicklich (IT Expert)
    • Kim Miller (Project Management)
    • Lin Guo (Statistical and analytical expertise)
    • Special consultants
      • Cec Montoye
      • Susan Bennett
      • Robin Trupp
  • 14.
    • HF Advocate role and responsibilities:
    • Facilitating credible & effective communications between HF patient & his/her physicians
    • Close direct patient/family follow up regarding HF medication and self-management compliance
    • Continuous assessment and timely linkages to critical and customized local HF patient support resources (including end-of-life care)
  • 15.  
  • 16. Conclusions
    • Many non-academic health systems do not have direct and ready access to nationally recognized clinical expertise for Heart Failure—such access can make a huge difference in quality improvement efforts
    • Appropriate organizational goals and incentives based upon standardized (ACC-AHA) quality measurements are powerful motivators for promoting and improving quality (Standardized “tools” are less important.)
    • Making the transition from focusing on acute hospital management to reducing hospital readmissions for HF is difficult and currently not profitable for most hospital systems; hospitals must now focus more on chronic care
    • Significant expertise in evidence-based HF care can be provided by well-trained “Heart Failure Advocates” without advanced-practice nursing training to improve quality of care and prevent readmissions for patients with chronic HF
  • 17. Heart Failure Advocate: A Critical Link to Chronic Care Coordination Presented By: Barb Markward RN, BSN, CCRN Heart Failure Advocate St. Rita’s Medical Center, Lima, Ohio
  • 18. CHP Heart Failure Advocates
    • Donna Kaiser: St. Elizabeth Health Center, Youngstown, Ohio
    • Rita Glesser: St. Charles Mercy Hospital, Oregon, Ohio
    • Tiffany Baird: Mercy Clermont Hospital, Batavia, Ohio
    • Grace Zite: St. Elizabeth’s Medical Center, Edgewood, Kentucky
    • Suzanne Reinhardt: Community Health Partners, Lorain, Ohio
    • Barb Markward: St. Rita’s Medical Center, Lima, Ohio
  • 19. Role of Heart Failure Advocate
    • Develop and implement a broad reaching quality improvement initiative for HF care management based upon translating research into practice.
    • Guide evidence based care for heart failure patients:
      • Evaluate all CHF(including HF history)patients
      • for:
      •  Left ventricular assessment
      •  ACEI/ARB and Beta Blocker use for LVSD
      •  Discharge follow up beneficial to the patient (including Home Care and CHF Clinic, OT/PT, SNF etc….)
    • Physician and Staff Education
  • 20. Goals of the HF Advocate
    • Build effective and influential relationships with MD’s, RN’s, and administrators to improve use of evidence-based decision-making for HF patients.
    • Evaluate and enhance the effectiveness of existing systems of HF care.
    • Participate in planning and convening of HF educational and quality improvement forums.
    • Impact the continuity of care, performance improvement and quality improvement while positioning the hospital well for Pay for Performance.
  • 21. Objectives for Heart Failure Advocate
    • Provide leadership across the continuum of care for the HF patient.
    • Implement staff education programs.
    • Initiate and coordinate patient education plans.
    • Coordinate care at all points along the continuum of care.
    • Assess hospitalized patients for use of evidence based medications.
    • Influence physicians to follow evidence-based practice
    • Facilitate communication among patients, physicians, and HF services.
    • Link patients to appropriate services: HF Clinic, Home Health, HF Call Center, Palliative Care and Hospice.
    • Provide patient tools and incentives to follow treatment regimen to referral agencies.
    • Follow up with referral agencies.
    • Communicate with all points of contact for patient services.
  • 22. Sample Leadership Training Opportunities
    • Orientation Workshop (3/04)
    • N-HeFT-Two day Advocate Training (5/04)
    • Case study workshop (8/04)
    • N-HeFT with physician champions (10/04)
    • OSU HF Clinic with physician champions (10/04)
    • Partnership Meetings (5/04, 10/04, 11/04)
    • HFSA Annual Meetings (9/04, 9/05, 9/06)
    • Breathe Symposia (10/04, 10/05 )
    • Cutting Edge HF Care Seminar (6/05)
    • HF at the Shoe OSU (11/05)
    • AHA (11/05)
    • AHA GWTG HF Workshops (3/05, 11/05, 3/06, 4/06)
    • Respecting Choices Workshop (1/06), (3/06)
    • TRIPP, (7/06)
  • 23. Building a network of Strength
    • Hospital champion
      • Team leader: communicating, facilitating and implementing
      • Commitment to collaboration for quality
      • Power to make changes
    • Physician champion
      • Credibility with peers and superiors
      • Commitment to “doing the right thing for the right reason”
      • Willingness to be a change agent
    • Hospital team
      • Department Managers: ER, ICU, CCU
  • 24. Administrative Support
    • Willingness of hospital CEO to provide resources.
    • Involvement and active support of VP and director in the quality initiative.
    • Utilization of multi-disciplinary team dedicated to improving outcomes for HF.
    • Strong support of physician champion to influence patient care.
  • 25. Multi-disciplinary Team of care
    • Multiple departments in the hospital
      • CCU/ICU, ER, Medical Surgical, Dietary, Cardiac Rehab, Pharmacy, Finance, Quality, Risk Management
    • Multiple outpatient points of care
      • Home care, Nursing Home, Skilled nursing, Palliative care, Hospice, physician office, heart failure clinic, Tele-management call center
    • Multiple specialists : Cardiologists, Internal Medicine, Nephrologists, Psychiatrists, Psychologists, Social workers, Case managers, Department Managers
    • External Service Providers : Department of Veteran Affairs, HMO’s
    • Families
    • Patients
  • 26. Advocates: the Missing Link to Services
    • Initiated use of a referral form listing all HF services to facilitate physician referrals.
    • Held conferences and luncheon in-services to educate nursing staff.
    • Developed HF Education seminars for Healthcare providers including Home Health, Skilled nursing facilities, ECF’s, Assisted and Independent Living facilities, Health Depts, Techs, ER staff etc.
    • Utilized a Call Center to assist with follow-up phone calls to HF patients.
    • Educated and utilized Parish Nursing volunteers to follow HF patients.
    • Held monthly HF Interdisciplinary Quality team meetings to review data and develop goals and strategies.
    • Developed standardized order sets for HF admission.
    • Utilized the Coronary Intervention Unit for HF Observation patients using rapid treatment order set.
  • 27. Role of Data in Quality Improvement
    • Data Management
    • Midas: Case Management Module
    • Midas: Core Measures
    • GWTG for HF
  • 28. Data summary
    • Analysis of the data has shown that patients under the care of the advocates had fewer readmissions and a longer time between readmissions than those patients not enrolled in the program.
  • 29. A Typical Day
    • Identify HF patients using Case Management Sheets.
    • Review charts for Core Measures and evidence-based medicine: measure of LV Function (Print past Cath reports and Echo’s for present chart.)
    • Utilize HF stickers on front of charts to prompt doctor and Case Managers.
    • Provide 2 copies of HF Care Notes discharge education sheets on chart (one of patient and one for chart).
    • Educate patients and families and begin discharge planning with patients and care managers .
    • Discuss patients’ needs with staff.
    • Write notes or discuss documentation and discharge needs with physicians.
    • Give scales and pill boxes to patients who need them.
    • Complete Midas data collection and GWTG for HF.
    • Do follow up phone calls for patients not followed by HF services.
  • 30. Advocate Successes
    • Provided standardized HF education, communication and coordination and improved outcomes along continuum of care
    • Changed physician attitudes , increased evidence- based practice and improved patient outcomes
    • Designed tools to improve the practice of evidence-based medicine improving Core Measures.
    • Established a Medication Assistance Program for HF patients.
    • Started a new HF Clinic.
    • Facilitated medication reconciliation
    • Utilized volunteers to improve patient care
  • 31. A story of Success: CM
    • CM-48 yr. old female, non-English speaking Hispanic with Hx of CHF, HTN, Diastolic Dysfunction with EF 45-50%. CM had 10 hospital admits from 1/04 to 6/04 R/T noncompliance issues. Daughters interpreted discharge instructions. Patient was referred to Medcare Clinic and CHF Clinic numerous times but never showed up for appointments.
      • • Referred patient to Medcare Clinic and attended apt with patient and caregiver.
      • • Intervened with physician and obtained referral to Home Health and the CHF Clinic.
      • • Visited home-no lasix, no scale. Educated Home Health RN, patient, and family and provided scale and pillbox.
      • • Integrated all services: CHF Clinic, Medcare Clinic, and Home Health.
      • • Patient and daughters reduced hospitalizations from 10 to 3 admissions 2 nd half 2004 R/T Renal Failure and 1 OBS stay in 2005.
      • • Patient was started on Hemodialysis 4/05 and moved to Columbus.
  • 32. HF CHART STICKER
    • ATTENTION PHYSICIANS
    • FOR ALL CHF PATIENTS
    • Medications at Discharge: Referrals:
    • EF % (within 1 yr)  CHF Clinic
    • ACE-I  CHF Call Center
    • ARB  Home Health
    • Beta Blocker
    • Nurses--Education
    •  HF Education  CHF Care Notes
    •  Smoking Cessation
    Sample
  • 33. HF Core Measures Report 99 99 100 97 96 94 Compliance Index 100 100 100 100 96 90 Patients receiving smoking cessation instructions 97 100 100 91 93 89 Patients treated with ACE inhibitors or ARB (for left ventricular dysfunction) before discharge 98 98 100 96 96 94 Patients having left ventricular function assessment documented 100 100 100 100 96 91 All discharge instructions completed                 Heart Failure Qtr 1 Mar Feb Jan 2005 2004 Core Measure
  • 34. Basic Principles of Change
    • All change is personal.
    • People don’t resist change—they resist being changed .
    • All change has both “positive” and “negative” consequences—no change is equally beneficial to everyone affected.
    • If no one’s uncomfortable, nothing is changing.
    • People will not willingly make changes they perceive to be “bad” for themselves (i.e., loss of time, status, money, etc).
    • If we want to change others we must first change ourselves.
    Effective change agents see the issue from the change target’s perspective.
  • 35. Advice for Creating A Chronic Care Model for your institution
    • Be persistent and patient as you build a new dynamic paradigm.
    • Respect the unique character of your institution.
    • Model the advocate role to fit your strong infrastructures already in place.
    • Build bridges from the old to the new. Not a ground zero construction zone.
    • Mold the Advocate to bridge the service lines to touch all points of care.
  • 36. Disseminating the program
    • Addition of Diabetic Advocate at one CHP hospital.
    • Addition of 3 new HF Advocates at CHP hospitals.
    • Plans to role the HF Advocate position into a Chronic Care Advocate at several locations.
    • Advocates speaking at AHA Quality conferences and national teleconferences.
  • 37. National Heart Failure Training Program N-HeFT
  • 38. National Network of experts
    • 30 Host Sites
    • Executive Council
    • Site Directors
    • Clinical Coordinators
  • 39. N-HeFT Mission
    • The National Heart Failure Training Program seeks to educate physicians and other healthcare professionals in best practices for treating heart failure by providing both didactic sessions and preceptorships through its network of heart failure centers across the country.
  • 40. PURPOSE OF THE NETWORK
    • Maintain best practices in the care and treatment of heart failure by
      • Promoting evidence-based care
      • Educating concerning pathophysiology, clinical diagnosis, clinical trials and therapy
    • Disseminate best practices to interdisciplinary teams who are eager to learn and enhance their care for HF patients
    • Continuously improve the quality of the program as an educational delivery system
  • 41. DESIRED OUTCOMES
    • Participants will identify 3 areas for change in their practice.
    • Physicians will implement changes in their practice to improve the quality of care of their heart failure patients.
    • N-HeFT host sites will facilitate 3 discussions with the participating sites within 90 days of the program to monitor the progress of the areas identified for change.
  • 42. Expanding our Influence Executive Council
  • 43.  
  • 44. Sites and Directors
    • Albany Medical Center
    • Edward F. Philbin, MD
    • Allegheny General Hospital
    • Srinivas Murali, MD
    • The Cardiovascular Center
    • Douglas Chapman, MD
    • Case Western Reserve University
    • Ileana Piña, MD
    • Duke University Medical Center
    • Christopher M. O’Connor, MD
    • Emory University Hospital
    • Andy Smith, MD
    • Midwest Heart Specialists
    • Maria Rosa Costanzo, MD
    • Northwestern University
    • William G. Cotts, MD
    • Ochsner Clinic
    • Hector Ventura, MD
    • Oklahoma Cardiovascular Associates
    • Philip B. Adamson, MD
    • Rush University Medical Center
    • Stephanie Dunlap, Md
    • South Florida Medical Institute
    • Gervasio Lamas, MD
    • St. Louis University
    • Paul J. Hauptman, MD
    • St. Luke’s Episcopal Hospital
    • Reynolds Delgado, MD
    • Temple University Hospital
    • Alfred Bové, PhD, MD
    • Tufts New England Medical Center
    • David DeNofrio, MD
  • 45. Sites and Directors
    • Univ. of California San Diego Medical Center
    • Barry Greenberg, MD
    • Univ. of California San Francisco Medical Center
    • Teresa DeMarco, MD
    • University of Cincinnati
    • Lynne Wagoner, MD
    • University of Colorado
    • JoAnn Lindenfeld, MD
    • University of Kansas Hospital
    • Charlie Porter, MD
    • University of Maryland
    • Stephen Gottlieb, MD
    • University of Minnesota
    • Les Miller, MD
    • University of New Mexico
    • Robert A. Taylor, MD
    • University of North Carolina School of Medicine
    • Kirkwood F. Adams, Jr., MD
    • University of Rochester
    • John Bisognano, MD
    • University of South Florida
    • Douglas D. Schocken, MD
    • University of Texas Southwest Medical Center
    • Clyde Yancy, MD
    • University of Washington Medical Center
    • Carol Buchter, MD
    • Washington University
    • Gregory Ewald, MD
  • 46. Curriculum Authors
    • Kirkwood Adams, MD
    • Mark Dunlap, MD
    • Doug Schocken, MD
    • Hector Ventura, MD
    • Mandeep Mehra, MD
    • Ron Oren, MD
    • Ileana Pi ñ a, MD
    • Lynne Wagoner, MD
    • Clyde Yancy, MD
    • Chris O'Connor, MD
    • Maria Rosa Constanzo, MD
    • Barry Greenberg, MD
    • Reynolds Delgado, MD
    • Theresa Demarco, MD
    • David DeNofrio, MD
    • Kimberly Huck, ND, RN
    • Kay Blum, PhD
    • Ginger Conway, MSN, RN, CNP
    • Srinivas Murali, MD
    • Kimberly Huck, ND, RN
    • Kay Blum, PhD
    • Ginger Conway, MSN, RN, CNP
  • 47. N-HeFT LIVE
    • Customized based on individual applications
      • One or two Day Training with Preceptorship
        • Small group interdisciplinary medical team visits 1/29 expert host sites of choice
        • Selected Topics based on identified learning needs of team
        • Training applied to practice
          • Practice improvement goals determined at end of training and submitted in writing
          • 30, 60, and 90 day follow up conference by host team
      • One day with patient panel, strategic planning workshop, etc.
  • 48. N-HeFT Online
      • Website: nheft.org
      • Online Curriculum
      • Audience
        • Cardiology
        • Primary Care
        • Allied Health
        • Site Directors, Clinical Coordinators, Faculty
  • 49. Program Quality
    • Evidenced-based curriculum-dissemination of best practice
      • Created, monitored and updated by committee of leaders in the field of heart failure
      • Host sites are selected as best practice models of care
      • All syllabi created at Case for disbursal to host sites
    • Quality continuing education
      • National Office at Case Western Reserve University:
        • Program administration, coordination, documentation, and training
      • Accreditation
        • AMA CME credit
        • Nursing credit
        • Pharmacy credit
        • American Academy of family Physicians
  • 50. Standardization of Training
      • Standardized Content and Processes
        • Online curriculum developed by network authors for continuing education
        • Training process standardized for faculty and participants
        • Detailed application for customized training reviewed at Case
        • Case manages application, enrollment, training and follow up
        • Password-protected slides and forms posted on web for faculty
        • Syllabus and supplemental materials prepared at Case
        • Resources for Professionals: sample quality tools, patient education, references
  • 51. Heart Failure Patient Advocate Mission
    • The heart Failure Advocate will provide evidence-based care that has been shown to improve the quality of life for heart failure patients
  • 52. Expected outcomes
    • The HF Advocates will implement changes in their system to improve the quality of care of their heart failure patients specifically in the area of mortality and hospital readmissions
  • 53. Partners for Quality in Training
    • Co-Investigators
      • Ileana Pi ñ a, MD
      • Bill Abraham, MD
      • Margie Namie, RN, MPH
      • Susan Bennett, RN, DNS
      • Robin Trupp, RN
      • Raha Mostajabi, ANP
      • Lynn Barrow, RN, MBA
    • N-HeFT
    • OSU
    • GWTG
  • 54. Role of the Advocate
    • Impact systems outcomes
      • Promote and market best practice care internally and externally
      • Coordinate care
        • Start Discharge planning in ER
        • Facilitate transfers, discharge, placement in rehab
        • Follow up
      • Improve performance and outcomes
      • Educate providers, patients, families, and caregivers
      • Monitor and Influence decision-making along continuum of care
  • 55. Advocate Training Day I Initial Training
    • 8:30 AM Welcome and Introductions
    • 8:30 HF 101
    • 12:00 Lunch with HF staff
    • 12:30PM Disease Management
    • 1:30 In-patient preceptorship
  • 56. Advocate Training Day 2
    • 8:00 Discharge Planning
    • 9:00 Clinic preceptorship
    • 11:00 Self Care
    • 11:45 Lunch with HF staff
    • 12:30 Day in the Life of an Advocate
    • 2:00 Quality of Life
    • 2:30 End of Life
    • 3:30 Networking
    • 4:00 Data Management
  • 57. Advocate Training Phase II with Physician Champion
    • Disease Management strategies through the life cycle of heart failure,
    • Conduct on-going Patient Education focusing on self-efficacy
    • Setting up A HF Program:
    • Managing Change
    • Effective Communication
  • 58. Dissemination
    • CHP: HF Advocate
      • 2 Advocates in Cincinnati
      • May 22-23
    • Advocate Mentors
  • 59. Training Summary
    • Ongoing
    • Multi-faceted Management
      • Chronic Disease with multiple co-morbidities
      • Systems with many layers and players
      • Data and documentation from many sources
      • Providers of care not connected
      • Patients and care givers –adherence to treatment plan
      • Many roles and activities and too little time
    • Requirements
      • Organization’s commitment to provide tools and resources for success
      • Advocate’s commitment to be a change agent creating a powerful coalition for patient care