Urgent Heart-Failure Clinics as Hubs for Fully Integrated Care

The Challenge

Roughly 5.1 million patients in the U.S. have heart failure (HF), at an estimated cost of $32 billion per year. At Geisinger Health System, we set out to achieve value-based care in heart failure by building on our decade-long record of innovative system integration.

In 2013, our ProvenCare^® Heart Failure program launched a disease-specific order set of measurable best practices in emergency department (ED) and inpatient care. The result was that hospital stays for HF became shorter and HF-related inpatient mortality rates dropped substantially. However, given that HF readmission rates did not decline, we recognized that we must address HF care in the outpatient setting more deliberately.

The Goal

We decided that any unplanned admission for acute HF that requires diuretic therapy alone (without surgical, procedural, or critical-care interventions) is a sentinel event. Our aim: Create immediate-access, multidisciplinary care units — comprising a broad team of trained, community-based nurse case managers — that fully coordinate HF services for these patients.

The Execution

Through a grant from Geisinger’s Quality Fund, in 2014 we established a single, centralized urgent heart failure (UHF) clinic at our main campus in central Pennsylvania. (A cardiology clinic provides this service in our western region, and a mobile-health paramedic pilot provides real-time diuretic interventions in patients’ homes in our northeast region.) The UHF model has three core functions: onsite clinical-expert review of the patient’s overall care plan; coordination between a patient’s assigned HF nurse navigator and community-based nurse case managers; and intensive medication management.

Here’s how the UHF clinic serves a typical patient, whom we’ll call Ms. Jackson:

Ms. Jackson, 79 years old, has end-stage chronic systolic heart failure and was discharged from the hospital three weeks ago. At home, she notices increasing shortness of breath and progressive weight gain. Her case manager activates a diuretic treatment protocol, which does not ameliorate her symptoms, and initiates UHF contact (with Ms. Jackson’s permission). The table below outlines the basic steps of the UHF process, along with some of the specific findings and activities for Ms. Jackson.

In 2015, 66% of Geisinger’s UHF patients received intravenous diuretics. The single observation unit is reserved for patients whose symptoms are severe enough to warrant an overnight stay but who are well enough to avoid a >48-hour hospital admission. If a patient is unwilling or not sick enough to stay overnight, but needs more than a single dose of IV diuretic therapy, the IV is left in place and diuretics are continued for two to three days at home, managed by an accredited home-care agency. This process, called virtual observation, is monitored by Geisinger’s HF nurse navigator (see steps 6 and 7 in the table).

All clinical team members use our INSPECTED algorithm, a methodical approach to assessing HF patients and their possible need for long-term and ongoing case management. (For detailed descriptions of the 9 elements of the INSPECTED algorithm, see the figure.) Case discussions among team members are conducted through the electronic medical record, by phone, face-to-face in corridors, and at monthly medical-home meetings. This routine coordination makes it easier to implement care plans and eliminate gaps in care, with direct involvement by the UHF when needed. Patients can also be referred from the UHF to clinical nutritionists, physical therapists, and cardiac rehabilitation programs.

The Team

Each core member of the UHF clinic team has clear roles that, though distinct, have care integration as a primary aim:

Nurse navigators gather information from nurse case managers or directly from clinical providers and then alert advance practice clinicians (APCs) when a patient requires a UHF clinic visit. (The APCs can involve a HF cardiologist, an electrophysiologist, or a pharmacist as needed.) The navigators serve as experts on best practices, provide intensive education to patients, advise nurse case managers on next steps for challenging patients, and attend HF team meetings.

Nurse case managers coordinate care transitions during the post-acute period. They also help to manage patients’ chronic diseases through detailed medication reconciliation, coordinated diuretic-treatment protocols, tracking of medication responses, and overall monitoring of patients’ health status. In addition, case managers have expertise in identifying which patients are ready for advanced-care planning and in providing patient education and resources (such as durable medical equipment). Case managers who focus on the most-complex patients — “commando nurses” — have greater clinical expertise and serve as an educational resource to patients and community-based case managers. They may also accompany patients to provider visits.

Pharmacists serve four key functions: modifying or eliminating potentially harmful medications (e.g., NSAIDs); efficiently titrating evidence-based medications (e.g., beta-blockers) to achieve targets even between patients’ visits; monitoring drug levels, metabolic effects, and side effects of medications (e.g., digoxin, spironolactone); and tracking patients’ adherence to their drug regimens. Pharmacists and case managers align their work closely to support the treating physician. (This model was inspired by our anticoagulation-program pharmacists, who have achieved worldwide recognition for low complication rates related to anticoagulation.)

The Metrics

Several preliminary metrics show the impact of Geisinger’s UHF clinic model:

• In 2013, only 4% of hospitalized HF patients avoided the ED; that number rose to 28% in 2015. Given that the average ED visit costs $1272 per event, approximately $240,000 were saved in ED visits.
• In 2015, some 278 UHF patients received IV diuretic therapy without going to the ED (i.e., went home), avoiding an estimated $353,000 in ED-related spending. A better patient experience by avoiding the ED, when possible, cannot be assigned a dollar value.
• We are still analyzing our data on medication management. So far, we know that monitoring of digoxin levels has increased from 31% to 78% and that monitoring of potassium and renal function has increased from 41% to 80%.

For their valuable contributions, we thank Joann Sciandra, Geisinger’s VP of Population Health; Michael Evans, AVP System Therapeutics; Chad Francis, Director of Quality Metrics and Analytics; and Jeff Adams, VP of the Heart Institute.