Heart Failure Care at UC Davis Kathleen Tong, MD Associate Clinical Professor Director, Heart Failure Program Director, Cardiac Rehabilitation Co-director, Ventricular Assist Device Program

Disclosures Speaker’s Bureau for Novartis

UC Davis Outcomes UC Davis Benchmark Risk Adjusted Mortality 1.5% 2.9% Statewide 30 Day Readmissions 21.3% 21.6% National What is our process to maintain lower than average mortality, but also to ensure less hospital use?

What is heart failure? A condition arising as the end stage of many different possible cardiac disease that results in dysfunction of the heart that leads to congestive symptoms such as shortness of breath and fluid retention. It is chronic and progressive No cure For many patients, HF is manageable and congestive symptoms are frequently alleviated with medications, fluid status monitoring, and a low sodium diet and fluid restriction. Good patient self care can be a large factor in the success of the treatment plan

CASE STUDY “Sheila” 61 year old woman with interstitial lung disease and heart failure with preserved ejection fraction (“diastolic heart failure). She has three hospitalizations for chest pain, shortness of breath within 2 months. Shortness of breath improves with diuretics She is also simultaneously treated for lung disease Normally she walks 7 miles a day, now cannot walk as far

Communication needed for optimal care Inpatient team to patient communication Discussion of diagnosis, communicate short term care plan Inpatient team to outpatient primary care provider (PCP) communication PCP review of records in the outpatient setting Challenging without connected EMRs PCP to specialists Is it heart related, lung related? Should we change therapy Patient to provider My symptoms are…. Providers back to patient Often done through nurses, medical assistants

Transition of Care (TOC) Admission to Discharge Transition Period First Outpatient Visit Medication reconciliation Education about diagnoses/warning symptoms Follow up appointments/referrals Follow up labs/studies Durable medical equipment Home health Transition to a non-home environment such as acute rehabilitation or skilling nursing Vulnerable time for patients New diagnoses Multiple medication changes

UC Davis Heart Failure After CMS announces penalties for heart failure (HF) readmissions, health systems examined their process for managing heart failure patients In 2010, this was the UC Davis Heart Failure Program (one doctor, one nurse)

Patient Flow – Single Provider Patient gets sick Patient goes to doctor’s office Patient admitted to hospital Patient gets better Transition of Care Needs Education New prescriptions New equipment Follow up appointments Patient goes to doctor’s office Patient goes home

Advent of the hospitalist PROS In house physician available for patients at all times Better rested physician Reduce medical errors? Inpatient specialist CONS Increases number of handoffs Physician caring for patient in hospital may not be physician who knows patient best Less patient ownership? Lower patient satisfaction? Separation of inpatient and outpatient care (ca. 1990s) Doctors engage in shiftwork

Patient admitted to hospital Primary Team Attending, Fellow, Resident, Intern Primary Team Attending, Fellow, Resident, Intern Night shift Patient goes to doctor’s office Consultants Consultants Discharge Summary Day of Discharge Attending Fellow, Resident, Intern’s day off

UC Davis TOC Team Inpatient Heart Failure Transition of Care (TOC) Team began in 2011 Started with NP and PharmD Pharmacy has now restructured and pharmacy position is nested with a separate pharmacy medication reconciliation and transition of care process Now we are NP, PA, and RN Primary Care Network, HF RN liason Works with high risk, complex patients followed in the PCN Goes to office visits, phones frequently, case management Intervention can last past 30 days Mission: Identify HF patients, educate them, facilitate transition to outpatient setting

UC Davis Inpatient TOC Roles Proactively identify heart failure patients who are hospitalized “Screening”: looking at admission lists for cardiology and general medicine teams  Still a manual chart review process, not automated Educate heart failure patients while hospitalized on their condition and self care needs, role of medications and identify barriers to care Make post-discharge phone calls Assist with appointment making for patients Identify patients who may benefit from HF Clinic Identify patients who are end stage who need advanced heart failure therapies such as transplant or VAD

CASE STUDY “Sheila” After the third hospitalization, her cardiologist refers her to the heart failure clinic for further recommendations for management at the suggestion of the inpatient TOC team She is seen by the heart failure cardiologist and RN Heart failure nurse finds that dosing her diuretics is difficult. She becomes fluid overloaded easily and fluid depleted easily with small changes in her diuretic doses despite weighing herself daily It is difficult to differentiate between her heart failure symptoms and lung symptoms

Home Monitoring Many home monitoring platforms are available We provide patients with a scale when they are discharged if they do not have one. Many insurance providers are providing scales and pairing it with phone calls from advice nurses The data for home monitoring is spotty Many small trials Low patient adherence rate A robust way to monitor heart failure patients is using the CardioMEMS device Implantable pulmonary artery pressure monitor High pressures  Congestion  Triggers treatment

CardioMEMS PA pressure increases before patients experience weight gain or symptoms Identify HF exacerbation early and treat based on pressure measurements

CHAMPION Trial: Hospital Admissions For HFpEF NNT = 4

CASE “Sheila” After intensive case management, patient remains out of the hospital, but still symptomatic She is offered a CardioMEMS device It is successfully implanted Her CardioMEMS data is monitored by the HF Clinic NP and medications are adjusted as needed based on her pulmonary pressures She has not been readmitted for 2 years Symptoms much improved and she is back to walking 7 miles a day

Inpatient Heart Failure Team Joint venture between the hospitalist group and the HF cardiologist to treat advanced HF patients Patients are co-managed Daily rounds together HF specialist manages cardiac issues Hospitalist manages other co-morbidities Most HF patients have multiple co-morbidities including DM, COPD, wounds Hospitalists rotate, so in any given year at least 10-15 of them have exposure to HF management Many use knowledge they acquire to take care of patients on the general medicine services

Heart Failure Clinic Today MD X 2, heart failure board certified RN, heart failure certified Case manages complex HF patients, heart transplant patients Reinforces education, communicates with board and care, SNF NP added in 2013 Sees HF patients in hospital discharge Sees patients who need close follow up Watches the CardioMEMS patients Other clinic capabilities IV Loop Diuretics IV Fluids ICD and pacemaker checks on site Radiology available in building

UC Davis HF Program Hospital Home Skilled Nursing PCN Liason Inpt HF team HF Clinic HomeHealth HF TOC Advanced HF team

Summary UC Davis has grown the Heart Failure Program in response to a growing need for coordination of care Goals were to ensure patient safety, direct patients to guideline based medications and devices, and guide patients to a sustainable self-care plan Very little of what we do is automated or by rote Patient centered care is at the heart of our interventions. We care for a large number of complex patients and we need a dedicated, heart failure minded team to care for our patients

UC Davis 2017 … and many more!

Round Table Question Intensive patient case management programs have been shown to be effective? Is this a sustainable model?