1. 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

2. Disclosures
Speaker’s Bureau for Novartis

3. 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?

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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

17. CHAMPION Trial: Hospital Admissions
For HFpEF
NNT = 4

18. 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

19. 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 of them have exposure to HF management
Many use knowledge they acquire to take care of patients on the general medicine services

20. 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

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

22. 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

23. UC Davis 2017
… and many more!

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