Heart Failure Clinic a Multidisciplinary approach. Amy Benson, PA-C, MSPAS Presbyterian Heart Group Albuquerque, NM
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1 Heart Failure Clinic a Multidisciplinary approach Amy Benson, PA-C, MSPAS Presbyterian Heart Group Albuquerque, NM
2 Disclosure I have no actual or potential conflict of interest in relation to this program/presentation.
3 Objectives 1. Recognize the value of a Team approach/multidisciplinary Care. 2. Recognize the value of utilizing Advanced Practice Clinicians in the Outpatient HF Clinic.
4 PHG HF Team Team-3 Advanced Practice Clinicians, 1 Clinical Pharmacist, Heart Failure Physicians, Registered RNs, and a Clinical Care Coordinator 40+ patient visits/day Diagnosis, guideline-directed medical therapy, identification and timely referral for advanced heart failure therapies (AICD, CRT-D, LVAD and transplant) Medication titration with clinical pharmacist for heart-failure specific medication reconciliation
5 Comprehensive Disease Management Program Hospital follow-ups seen within a week of discharge by an APC. Outpatient PCP referrals go directly to Dr. Macias, our Advanced Heart Failure Cardiologist. APC education of HF, review of recent events of hospital course, anticipated plan of care. RN heart failure education, including nutrition counseling at initial visit. Medication reconciliation/titration by our Clinical Pharmacist. Close monitoring of labs and f/u with aggressive up-titration of medications IV diuresis, only with recent labs
6 Comprehensive Disease Management Program Close outpatient follow up to avoid ED visits (days, weeks, months) Same-day imagining (Echo, MUGA) Same-day labs Onsite care coordination-maximize patient care home services Referrals to Cardiac Rehab when appropriate
7 Comprehensive Disease Management Program Expedited access for direct hospitalization Access to novel pharmacological treatment with financial assistance Timely referral of advanced heart failure therapies (ICD, CRT, etc) A nurse and Health Planet Heart Failure Registry care manager Monthly follow-up with Presbyterian HF Core Team
8
9 Key Principles of Meeting educational needs Education Information should be provided in small amounts, at regular intervals, to improve uptake and retention. Information should be provided in oral and written formats, and other formats (ie: web-based, videos) Education should also involve family members/caregivers to ensure support in the home. Multidisciplinary team members should regularly followup with patients and caregivers to confirm understanding. (J.P.Riley and J. Masters)
10 2004-JACC Multidisciplinary strategies for the management of patientts with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations.
11 IMPROVe HF IMPROVE HF-Registry to improve the use of evidence-based heart failure therapies in the outpatient setting. Community-based practices with no academic affiliations Study looked at the influence of APN and PA staffing on the delivery of guideline-recommended therapies for patients with HF in outpatient cardiology practices from Core Measures-4 involved drug therapies: ACEIs or ARBs, BBs, AC for atrial fibrillation, and aldosterone antagonists. Compared to no APCs, 2 APCs was associated with increased use of ICDs and delivery of HF education, and equivalent use us drug and CRTs.
12 Collaborative Care Model Adopting a collaborative care delivery model has been identified as one way to help ease the burden of physicians faced with an influx of patients insured under the Affordable Care Act and a projected shortage of PCPs and specialists, which is expected to reach 90,000 by ACC 2015 Press Release National Cardiovascular Data Registry PINNACLE Registry-records from 2012 (648,909 patients in 90 practices with 1,234 providers) Determine compliance with established performance measures BBs with hx of MI Antiplatelet use Smoking screening, interventions to quit Cholesterol control Referral to cardiac rehab Anticoagulation with afib patients
13 459,669 patients were treated by physicians in practices with either PAs or NPs among 41 practices-compared to practices with physician-only models Conclusion: compliance with performance measures for CAD, HF and afib were all comparable across all practice types and clinicians. Higher rate of screening for smoking, interventions to quit, higher rate of referral to cardiac rehab amongst APCs compared to Physicians. Collaborative care delivery model employing both physicians and APCs delivers quality care comparable to physician-only models. Direct link between care and patient outcome still needed. Change in cost with team-based care to changes in patient outcomes.
14 PHG Quality Survey HF Quality Initiative Survey No preference APC Cardiologist
15 Limitations Patients don t follow up as recommended Time, insurance, rural location constraints Lack of education for HF patients Poor compliance with diet, tobacco, ETOH, and drug abuse Difficulty with getting consults to our HF clinic Complex disease process, comorbidities Low income population with unavailability of resources Compliance to treatment & cost of medications Optimize data collection mechanism/coding
16 PHG Outpatient Resources Presbyterian Healthplex-Cardiac Rehab (HFrEF only) Presbyterian Hospital at Home Presbyterian Home Health Care Presbyterian Complete Care, Palliative and Hospice
17 PHG CHF Clinic Future Goals Social worker CHF support group for patients Dietician Inpatient HF Team HF Telemedicine program Dedicated Infusion Suite/Continuous Telemetry Continued surveying of patients/family/caregivers
18 References Albert N, Fonarow G, Yancy C, Curtis A, Stough W, Gheorghiade M. Outpatient Cardiology Practices with Advances Practice Nurses and Physician Assistants Provide Similar Delivery of Recommended Therapies (Findings from IMPROVE HF). American Journal of Cardiology 2010;105: Riley J, Masters J. Practical multidisciplinary approaches to heart failure management for improved patient outcome. European Heart Journal Supplements (Supplement G), G43-G52. Cardiac Patients Receive Comparable Care from Physician, Advanced Practice Providers Jain A, Mills P, Nunn L, Butler J, Luddington L, Ross V. Success of a multidisciplinary heart failure clinic for the initiation and up-titration of key therapeutic agents. The European Journal of Heart Failure Manning S, Wendler M, Baur K. An innovative approach to standardizing heart failure care:the heart failure support team. Journal of the American Academy of Nurse Practioners Dahl J and Penque S. APN spells success for a heart failure program. Nursing Management February McAlister F, Stewart S, Ferrua S, McMurray J. Multidisciplinary Strategies for the Management of Heart Failure Patients at High Risk for Admission. Journal of American College of Cardiology 2004:44: Clark A, Savard L, Thompson D. What is the strength of evidence for heart failure disease-management programs? Journal of American College of Cardiology 2009;54:
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