Managing HF patients throughout continuum
Team works with payers, providers
At St. Joseph's Hospital in Tampa, a multidisciplinary team collaborates with clinicians throughout the continuum to manage the care of heart failure patients.
In the new program, the hospital has worked with HealthPoint Medical Group to develop a comprehensive program that provides individualized treatment for heart failure patients.
"Heart failure represents a growing population of patients, as well as being the most expensive group of patients receiving Medicare benefits. Tampa has a readmission rate for heart failure that is higher than the national average. This makes us very interested in determining why these patients continue to be admitted and readmitted to the hospital and to help them learn to manage their disease," says Gus Agocha, MD, PhD, director of the Congestive Heart Failure Care program.
The heart failure team includes Agocha, a nurse case manager, and a nurse practitioner who work with the cardiologists who treat patients in the hospital, the hospital's heart failure nurse advocate who provides care coordination and education to heart failure patients in the hospital, and primary care physicians in the community. "Our program is collaborative and transcends the hospital walls. We emphasize to clinicians throughout the continuum that we are not coming in and taking over care. We are coordinating a uniform care plan to make sure everybody is on the same page and is giving the same message to the patients," he says.
The program provides a central telephone number that all clinicians, patients, and family members can call whether the patient is in the hospital, in the home, the physician's office, or a skilled nursing facility, Agocha says. The program is only a few months old, but the team already has anecdotal data to show that patients are calling the heart failure nurse instead of going to the emergency department.
"We are available if caregivers or providers have questions or concerns. If the nurses in the hospice program or the home healthcare agency have questions, they know to call us. Patients sometimes end up in the emergency department because the home health nurse has questions and can't get in touch with the primary care physician. Now they can call us," he says.
When patients are hospitalized with heart failure, Agocha meets with the attending physician and talks with the patient's primary care physician to discuss the patient, then reviews the medical record and the patient's history. The team develops a care plan consistent with the patient's stage of heart failure.
"When patients are frequently admitted, it helps to have a set of fresh eyes to look at what is going on. In addition it is helpful for me to have a conversation with a physician who has managed the patient for a long time to get their thoughts. Together we can come up with a plan for the patient," Agocha says.
The heart failure team sees every heart failure patient in the hospital. Agocha meets with them initially and educates them about their disease and medication. Then, the nurse case manager follows up and reinforces the teaching, conducting lifestyle counseling to help the patient improve diet and exercise and manage smoking habits.
"What is lost in a lot of education is the fact that heart failure is progressive. We educate patients to understand that if they follow their treatment plan, they can slow down the progress of heart failure so much that it seems like it stops," he says. The team uses diagrams and pictures to show patients and family members what happens as the disease progresses to emphasize why it's important for them to follow the treatment plan.
When patients are discharged, they come to the heart failure clinic, located next to the hospital, within three to five days. The team makes sure they have filled their prescriptions and that they know who to call if they gain weight or experience other symptoms.
Many heart failure readmissions occur because patients aren't seen by a medical professional in a timely manner, Agocha says, adding that about 80% of heart failure patients who come to the emergency department are admitted.
"Our goal is to see patients early enough and to work with them and their providers to cut down on the readmissions. We are absolutely focused on the patient and making sure they understand what they need to do. Currently there is not cure for heart failure, but we can help patients slow the progress of the disease," he says.
At St. Joseph's Hospital in Tampa, a multidisciplinary team collaborates with clinicians throughout the continuum to manage the care of heart failure patients.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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