Care Redesign

Urgent Heart-Failure Clinics as Hubs for Fully Integrated Care

Case Study · March 23, 2016

Geisinger Health System fully integrates its high-quality care for patients with heart failure through a disseminated but well-coordinated network of nurse case managers, nurse navigators, pharmacists, and urgent heart-failure clinics. The result: fewer ED visits and better medication management.

Key Takeaways

  1. High-quality, integrated, multidisciplinary teams can be organized around heart-failure care.

  2. Heart-failure clinical experts can effectively disseminate, implement, and monitor care plans through community partnerships with nurse case managers.

  3. A unified approach to assessing heart-failure cases through the electronic medical record, by phone, and during face-to-face encounters helps to integrate the work of multidisciplinary teams.

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.

Basic Steps in Geisinger Urgent Heart Failure Clinic Care: Table

Table 1: Geisinger Urgent Heart Failure Clinic Care. Click To Enlarge.

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.

Geisinger Urgent Heart Failure Clinic Care: Figure

Figure 1: Geisinger Urgent Heart Failure Clinic Care. Click To Enlarge.

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.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Summary of Comprehensive Approach to Physician Behavior and Practice Change

Engaging Stakeholders to Produce Sustainable Change in Surgical Practice

How an initiative designed to improve patient outcomes and satisfaction while containing costs led to sustainable change in surgical practice and physician behavior.

Myths and Realities of Opioid Use Disorder Treatment.

Primary Care and the Opioid-Overdose Crisis — Buprenorphine Myths and Realities

There is a realistic, scalable solution for reaching the millions of Americans with opioid use disorder: mobilizing the primary care physician (PCP) workforce to offer office-based addiction treatment with buprenorphine, as other countries have done.

Coffey02_pullquote family-centered care in medical and surgical procedures

What If Family-Centered Care Were Extended to Medical and Surgical Procedures?

Though the concerns are valid, early experiences suggest that family member engagement may be an effective tool for improving the value of care.

Evidence Needed for Health Systems Change to Address Social Determinants of Health and Obesity and Diet-Related Diseases in Turn

Better Clinical Care for Obesity and Diet-Related Diseases Requires a Focus on Social Determinants of Health

To more effectively treat the problems of obesity and diet-related conditions, health systems need to restructure the traditional medical model of care delivery to address the social determinants of health.

People Living with Dementia Around the World - Value-Based Chronic Illness and Dementia Care

Value-Based Care Must Strengthen Focus on Chronic Illnesses

To effectively control costs and improve value, new models must address our increasingly older patients and chronic care patients, especially those with Alzheimer’s and related dementias.

The Barriers to Excellent Care Vary Widely Across Geographic Regions - both Rural Health Care and Urban Health Care

Survey Snapshot: Rural Health Innovations Born from Challenges

According to NEJM Catalyst Insights Council members, every health system has to develop its own definition of what is meant by “rural” health.

Same-Day Breast Biopsy Workflow at Baylor College of Medicine

How Care Redesign and Process Improvement Can Reduce Patient Fear

Seeing how clinicians take care of their own when they are in frightening situations was the epiphany that led to a same-day breast biopsy program.

Rural Health Care Is Rated Comparable or Worse Across Quadruple Aim Aspects

Care Redesign Survey: Lessons Learned from and for Rural Health

Although care delivery models in rural and urban/suburban areas are distinct, by virtue of geographic density and resource availability, each locale affords lessons for the other.

Comprehensive Intervention Review at Lurie Childrens Hospital - improving patient flow and length of stay

Reducing Length of Stay in the ED

A comprehensive redesign of triage and ED care.

Pumonary Nurse Post-Discharge Follow-Up Note for Patients with COPD

TOPS: Telephonic Outreach in the Pulmonary Service at VA Boston Healthcare System

A nurse-directed intervention targeting veterans who had been hospitalized for COPD resulted in improved access to ambulatory care and a reduced rate of readmissions.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Social Needs

88 Articles

Better Clinical Care for Obesity and…

To more effectively treat the problems of obesity and diet-related conditions, health systems need to…

A Successful Pilot to Improve Access…

Actionable data and modest financial incentives can help motivate clinicians to adjust their behavior around…

Coordinated Care

129 Articles

The Evolution of Primary Care: Embracing…

Primary care must leverage disruptive innovations to ensure that patients receive first-access, comprehensive, coordinated, continuous…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now