nheft.org

Catholic Healthcare Partners’ Catholic Healthcare Partners’ Closing the “GAP” Closing the “GAP”

for Heart Failurefor Heart Failure

Don Casey MD, MPH, MBA, FACP*Don Casey MD, MPH, MBA, FACP*Chief Medical Officer and Principal Chief Medical Officer and Principal

InvestigatorInvestigatorCatholic Health Partners (Cincinnati, OH) Catholic Health Partners (Cincinnati, OH)

June 28, 2006June 28, 2006

*Currently Vice President, Quality & Chief Medical Officer *Currently Vice President, Quality & Chief Medical Officer Atlantic Health, Morristown, NJAtlantic Health, Morristown, NJ

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

1977 2001

Annual HF Discharges in the US

Catholic Healthcare Partners

ToledoLorain

Lima

Springfield

Cincinnati

Kentucky/Indiana

Tennessee

Northeast PA

Youngstown/Warren

No. Kentucky

• 10 Regional Health Systems – Emphasizes the local community and promotes integrated continuum of care

• System Office - Provides oversight and select centralized services.

31 Hospitals 16 Long-Term Care/Nursing

Homes 19 Elderly Housing 10 Home Health Agencies 5 Cancer Centers 8 Freestanding Outpatient

Surgery Centers

Catholic Healthcare Partners

Heart Failure Statistics (2002)

In-Hospital Mortality Rate 4%

Number of discharges Primary Dx HF 8,446

< Age 65 1,635 19%Age 65 or greater 6,868 81%

Male 3,595 43%Female 4,908 57%

White 7,561 90%Non-White 885 10%

RangeLow High

Average Cost per Case 5,246$ 3,404$ 7,218$ Average Length of Stay (days) 5.5 3.8 6.9 30 Day Readmission Rate 22% 17% 30%

Total Cost Primary Dx HF 44,305,292$

Number of discharges Secondary Dx HF 26,027

Priority areas for quality improvement addressed by the CHP HF-GAP project

Care coordination Self-management/Health literacy End of Life with advanced organ system failure Frailty associated with old age Ischemic heart disease Major depression Medication management Stroke Tobacco dependence treatment in adults

From: Priority Areas for National Action: Transforming Health Care Quality (2003)(IOM)

http://www4.nationalacademies.org/iom/iomhome.nsf

Strategic Goals for CHP HF GAP

Effective and lasting influences of expertise and energy of Partnership (including AHRQ) and its members upon the CHP system and its local regions

Organizational alignment of quality improvement initiatives, including senior management and governance understanding, acceptance, leadership and incentives

More effective care coordination post-hospital discharge, including end-of-life care

Enhanced cooperation and collaboration with physicians, especially with quality improvement efforts

Enhanced internal and external financial and non-financial incentives, especially “Pay for Performance”

Components of Successful Healthcare Delivery Models for Heart Failure

Physician-directed care with assistance from nurse coordinators in patient management or nurse-managed care by experienced advanced practice cardiovascular nurses with access to a cardiologist for consultation

Intensive, comprehensive patient and family/caregiver education about heart failure with an emphasis on a low-salt diet, medications, symptoms that signal worsening heart failure, weighing, and management strategies for problems

Vigilant, frequent follow-up after hospital discharge Optimization of medical therapy (ensuring patients are prescribed the

appropriate drugs in appropriate doses) with published guidelines based on large-scale randomized, controlled clinical trials

Information systems that support effective point-of-care evidence-based clinical decision making (e.g. registries, patient records, laboratory information, prompts and reminders, self-management tools, etc.)

Components of Successful Healthcare Delivery Models for Heart Failure (Part II)

Increased access to healthcare professionals for problems by telephone or “walk-in” appointment

Early attention to signs and symptoms of fluid overload (ie, flexible diuretic regimen)

Supplementation of in-hospital education with outpatient education

Coordination with home health agencies where appropriate Attention to behavioral strategies to increase compliance Emphasis on addressing personal, financial, and social barriers

to compliance Assessment and assistance in management of social and

financial concerns Adaptable to communities without academic medical centers Cost-effective and clinically relevant performance measurement

systems

Co-investigators• Don Casey (CHP CMO)• Margie Namie (CHP QMT)• William Abraham (National HF Expert)• Lynn Barrow (CHP CPOE/Clinical IT)• Ileana Piña (National HF Expert)• Rick Snow (Quality Improvement Expert)• John Schaeffer (Cardiologist Leader)• Rich Glicklich (IT Expert)• Kim Miller (Project Management)• Lin Guo (Statistical and analytical expertise)• Special consultants

– Cec Montoye– Susan Bennett– Robin Trupp

HF Advocate role and responsibilities:

•Facilitating credible & effective communications between HF patient & his/her physicians

•Close direct patient/family follow up regarding HF medication and self-management compliance

•Continuous assessment and timely linkages to critical and customized local HF patient support resources (including end-of-life care)

ConclusionsConclusions1.1. Many non-academic health systems do not have direct Many non-academic health systems do not have direct

and ready access to nationally recognized clinical and ready access to nationally recognized clinical expertise for Heart Failure—such access can make a expertise for Heart Failure—such access can make a huge difference in quality improvement effortshuge difference in quality improvement efforts

2.2. Appropriate organizational goals and incentives based Appropriate organizational goals and incentives based upon standardized (ACC-AHA) quality measurements upon standardized (ACC-AHA) quality measurements are powerful motivators for promoting and improving are powerful motivators for promoting and improving quality (Standardized “tools” are less important.)quality (Standardized “tools” are less important.)

3.3. Making the transition from focusing on acute hospital Making the transition from focusing on acute hospital management to reducing hospital readmissions for HF management to reducing hospital readmissions for HF is difficult and currently not profitable for most is difficult and currently not profitable for most hospital systems; hospitals must now focus more on hospital systems; hospitals must now focus more on chronic carechronic care

4.4. Significant expertise in evidence-based HF care can be Significant expertise in evidence-based HF care can be provided by well-trained “Heart Failure Advocates” provided by well-trained “Heart Failure Advocates” without advanced-practice nursing training to improve without advanced-practice nursing training to improve quality of care and prevent readmissions for patients quality of care and prevent readmissions for patients with chronic HFwith chronic HF

Heart Failure Advocate: A Critical Link to Chronic Care

Coordination

Presented By:Barb Markward RN, BSN, CCRNHeart Failure Advocate

St. Rita’s Medical Center, Lima, Ohio

CHP Heart Failure Advocates

Donna Kaiser: St. Elizabeth Health Center, Youngstown, Ohio

Rita Glesser: St. Charles Mercy Hospital, Oregon, Ohio

Tiffany Baird: Mercy Clermont Hospital, Batavia, Ohio

Grace Zite: St. Elizabeth’s Medical Center, Edgewood, Kentucky

Suzanne Reinhardt: Community Health Partners, Lorain, Ohio

Barb Markward: St. Rita’s Medical Center, Lima, Ohio

Role of Heart Failure Advocate

Develop and implement a broad reaching quality improvement initiative for HF care management based upon translating research into practice.

Guide evidence based care for heart failure patients: Evaluate all CHF(including HF history)patients for:

Left ventricular assessment ACEI/ARB and Beta Blocker use for LVSD Discharge follow up beneficial to the patient (including Home Care and CHF Clinic, OT/PT, SNF etc….)

Physician and Staff Education

Goals of the HF Advocate

Build effective and influential relationships with MD’s, RN’s, and administrators to improve use of evidence-based decision-making for HF patients.

Evaluate and enhance the effectiveness of existing systems of HF care.

Participate in planning and convening of HF educational and quality improvement forums.

Impact the continuity of care, performance improvement and quality improvement while positioning the hospital well for Pay for Performance.

Objectives for Heart Failure Advocate

Provide leadership across the continuum of care for the HF patient.

Implement staff education programs. Initiate and coordinate patient education plans. Coordinate care at all points along the continuum of care. Assess hospitalized patients for use of evidence based

medications. Influence physicians to follow evidence-based practice Facilitate communication among patients, physicians, and

HF services. Link patients to appropriate services: HF Clinic, Home

Health, HF Call Center, Palliative Care and Hospice. Provide patient tools and incentives to follow treatment

regimen to referral agencies. Follow up with referral agencies. Communicate with all points of contact for patient

services.

Sample Leadership Training Opportunities

Orientation Workshop (3/04) N-HeFT-Two day Advocate Training (5/04)o Case study workshop (8/04)o N-HeFT with physician champions (10/04)o OSU HF Clinic with physician champions (10/04)o Partnership Meetings (5/04, 10/04, 11/04) o HFSA Annual Meetings (9/04, 9/05, 9/06)o Breathe Symposia (10/04, 10/05 )o Cutting Edge HF Care Seminar (6/05) o HF at the Shoe OSU (11/05)o AHA (11/05)o AHA GWTG HF Workshops (3/05, 11/05, 3/06, 4/06) o Respecting Choices Workshop (1/06), (3/06)o TRIPP, (7/06)

Building a networkof Strength

Hospital champion Team leader: communicating, facilitating and

implementing Commitment to collaboration for quality Power to make changes

Physician champion Credibility with peers and superiors Commitment to “doing the right thing for the

right reason” Willingness to be a change agent

Hospital team Department Managers: ER, ICU, CCU

Administrative Support

Willingness of hospital CEO to provide resources.

Involvement and active support of VP and director in the quality initiative.

Utilization of multi-disciplinary team dedicated to improving outcomes for HF.

Strong support of physician champion to influence patient care.

Multi-disciplinary Team of care

Multiple departments in the hospital CCU/ICU, ER, Medical Surgical, Dietary, Cardiac Rehab,

Pharmacy, Finance, Quality, Risk Management Multiple outpatient points of care

Home care, Nursing Home, Skilled nursing, Palliative care, Hospice, physician office, heart failure clinic, Tele-management call center

Multiple specialists: Cardiologists, Internal Medicine, Nephrologists, Psychiatrists, Psychologists, Social workers, Case managers, Department Managers

External Service Providers: Department of Veteran Affairs, HMO’s

Families Patients

Advocates: the Missing Link to Services

Initiated use of a referral form listing all HF services to facilitate physician referrals.

Held conferences and luncheon in-services to educate nursing staff.

Developed HF Education seminars for Healthcare providers including Home Health, Skilled nursing facilities, ECF’s, Assisted and Independent Living facilities, Health Depts, Techs, ER staff etc.

Utilized a Call Center to assist with follow-up phone calls to HF patients.

Educated and utilized Parish Nursing volunteers to follow HF patients.

Held monthly HF Interdisciplinary Quality team meetings to review data and develop goals and strategies.

Developed standardized order sets for HF admission. Utilized the Coronary Intervention Unit for HF Observation

patients using rapid treatment order set.

Role of Data in Quality Improvement

Data Management o Midas: Case Management

Moduleo Midas: Core Measureso GWTG for HF

Data summary

Analysis of the data has shown that patients under the care of the advocates had fewer readmissions and a longer time between readmissions than those patients not enrolled in the program.

A Typical Day

Identify HF patients using Case Management Sheets. Review charts for Core Measures and evidence-based medicine:

measure of LV Function (Print past Cath reports and Echo’s for present chart.)

Utilize HF stickers on front of charts to prompt doctor and Case Managers.

Provide 2 copies of HF Care Notes discharge education sheets on chart (one of patient and one for chart).

Educate patients and families and begin discharge planning with patients and care managers.

Discuss patients’ needs with staff. Write notes or discuss documentation and discharge needs with

physicians. Give scales and pill boxes to patients who need them. Complete Midas data collection and GWTG for HF. Do follow up phone calls for patients not followed by HF services.

Advocate Successes

Provided standardized HF education, communication and coordination and improved outcomes along continuum of care

Changed physician attitudes, increased evidence- based practice and improved patient outcomes

Designed tools to improve the practice of evidence-based medicine improving Core Measures.

Established a Medication Assistance Program for HF patients.

Started a new HF Clinic. Facilitated medication reconciliation Utilized volunteers to improve patient care

A story of Success: CM

CM-48 yr. old female, non-English speaking Hispanic with Hx of CHF, HTN, Diastolic Dysfunction with EF 45-50%. CM had 10 hospital admits from 1/04 to 6/04 R/T noncompliance issues. Daughters interpreted discharge instructions. Patient was referred to Medcare Clinic and CHF Clinic numerous times but never showed up for appointments.

• Referred patient to Medcare Clinic and attended apt with patient and caregiver.

• Intervened with physician and obtained referral to Home Health and the CHF Clinic. • Visited home-no lasix, no scale. Educated Home Health RN,

patient, and family and provided scale and pillbox. • Integrated all services: CHF Clinic, Medcare Clinic, and Home

Health. • Patient and daughters reduced hospitalizations from 10 to 3

admissions 2nd half 2004 R/T Renal Failure and 1 OBS stay in 2005. • Patient was started on Hemodialysis 4/05 and moved to

Columbus.

HF CHART STICKER

ATTENTION PHYSICIANSFOR ALL CHF PATIENTS

Medications at Discharge:Referrals:

EF % (within 1 yr) CHF Clinic ACE-I CHF Call Center ARB Home Health Beta Blocker

Nurses--Education HF Education CHF Care Notes Smoking Cessation

Sample

HF Core Measures Report

Core Measure 2004 2005 Jan Feb Mar Qtr 1

Heart Failure

All discharge instructions completed

91 96 100 100 100 100

Patients having left ventricular function assessment documented

94 96 96 100 98 98

Patients treated with ACE inhibitors or ARB (for left ventricular dysfunction) before discharge 89 93 91 100 100 97

Patients receiving smoking cessation instructions

90 96 100 100 100 100

Compliance Index 94 96 97 100 99 99

Basic Principles of Change All change is personal. People don’t resist change—they resist being changed. All change has both “positive” and “negative”

consequences—no change is equally beneficial to everyone affected.

If no one’s uncomfortable, nothing is changing. People will not willingly make changes they perceive to

be “bad” for themselves (i.e., loss of time, status, money, etc).

If we want to change others we must first change ourselves.

Effective change agents see the issue from the change target’s perspective.

Advice for Creating A Chronic Care Model for your institution

Be persistent and patient as you build a new dynamic paradigm.

Respect the unique character of your institution.

Model the advocate role to fit your strong infrastructures already in place.

Build bridges from the old to the new. Not a ground zero construction zone.

Mold the Advocate to bridge the service lines to touch all points of care.

Disseminating the program

Addition of Diabetic Advocate at one CHP hospital.

Addition of 3 new HF Advocates at CHP hospitals.

Plans to role the HF Advocate position into a Chronic Care Advocate at several locations.

Advocates speaking at AHA Quality conferences and national teleconferences.

Copyright CASE-CME Copyright CASE-CME 20042004

All Rights ReservedAll Rights Reserved

National Heart Failure Training

ProgramN-HeFT



National Network of experts

30 Host Sites30 Host Sites Executive CouncilExecutive Council Site DirectorsSite Directors Clinical CoordinatorsClinical Coordinators



N-HeFT MissionThe National Heart Failure Training The National Heart Failure Training Program seeks to educate physicians Program seeks to educate physicians and other healthcare professionals in and other healthcare professionals in best practices for treating heart failure best practices for treating heart failure by providing both didactic sessions and by providing both didactic sessions and preceptorships through its network of preceptorships through its network of heart failure centers across the country.heart failure centers across the country.



PURPOSE OF THE NETWORK Maintain best practices in the care and Maintain best practices in the care and

treatment of heart failure bytreatment of heart failure by Promoting evidence-based carePromoting evidence-based care Educating concerning pathophysiology, clinical Educating concerning pathophysiology, clinical

diagnosis, clinical trials and therapydiagnosis, clinical trials and therapy

Disseminate best practices to Disseminate best practices to interdisciplinary teams who are eager to interdisciplinary teams who are eager to learn and enhance their care for HF patientslearn and enhance their care for HF patients

Continuously improve the quality of the Continuously improve the quality of the program as an educational delivery systemprogram as an educational delivery system



DESIRED OUTCOMES Participants will identify 3 areas for change Participants will identify 3 areas for change

in their practice. in their practice. Physicians will implement changes in their Physicians will implement changes in their

practice to improve the quality of care of practice to improve the quality of care of their heart failure patients. their heart failure patients.

N-HeFT host sites will facilitate 3 N-HeFT host sites will facilitate 3 discussions with the participating sites discussions with the participating sites within 90 days of the program to monitor the within 90 days of the program to monitor the progress of the areas identified for change. progress of the areas identified for change.



Expanding our Influence

Executive Council



Sites and Directors

Albany Medical CenterAlbany Medical Center Edward F. Philbin, MDEdward F. Philbin, MD

Allegheny General HospitalAllegheny General Hospital Srinivas Murali, MDSrinivas Murali, MD

The Cardiovascular CenterThe Cardiovascular Center Douglas Chapman, MDDouglas Chapman, MD

Case Western Reserve UniversityCase Western Reserve University Ileana Piña, MDIleana Piña, MD

Duke University Medical CenterDuke University Medical Center Christopher M. O’Connor, MDChristopher M. O’Connor, MD

Emory University HospitalEmory University Hospital Andy Smith, MDAndy Smith, MD

Midwest Heart SpecialistsMidwest Heart Specialists Maria Rosa Costanzo, MDMaria Rosa Costanzo, MD

Northwestern UniversityNorthwestern University William G. Cotts, MDWilliam G. Cotts, MD

Ochsner ClinicOchsner Clinic Hector Ventura, MDHector Ventura, MD

Oklahoma Cardiovascular AssociatesOklahoma Cardiovascular Associates Philip B. Adamson, MDPhilip B. Adamson, MD

Rush University Medical CenterRush University Medical Center Stephanie Dunlap, MdStephanie Dunlap, Md

South Florida Medical InstituteSouth Florida Medical Institute Gervasio Lamas, MDGervasio Lamas, MD

St. Louis UniversitySt. Louis University Paul J. Hauptman, MDPaul J. Hauptman, MD

St. Luke’s Episcopal HospitalSt. Luke’s Episcopal Hospital Reynolds Delgado, MD Reynolds Delgado, MD

Temple University HospitalTemple University Hospital Alfred Bové, PhD, MDAlfred Bové, PhD, MD

Tufts New England Medical CenterTufts New England Medical Center David DeNofrio, MDDavid DeNofrio, MD



Sites and DirectorsUniv. of California San Diego Medical Univ. of California San Diego Medical

CenterCenter Barry Greenberg, MDBarry Greenberg, MD

Univ. of California San Francisco Medical Univ. of California San Francisco Medical CenterCenter

Teresa DeMarco, MDTeresa DeMarco, MD

University of CincinnatiUniversity of Cincinnati Lynne Wagoner, MDLynne Wagoner, MD

University of ColoradoUniversity of Colorado JoAnn Lindenfeld, MDJoAnn Lindenfeld, MD

University of Kansas HospitalUniversity of Kansas Hospital Charlie Porter, MDCharlie Porter, MD

University of MarylandUniversity of Maryland Stephen Gottlieb, MDStephen Gottlieb, MD

University of MinnesotaUniversity of Minnesota Les Miller, MDLes Miller, MD

University of New MexicoUniversity of New Mexico Robert A. Taylor, MDRobert A. Taylor, MD

University of North Carolina School of University of North Carolina School of MedicineMedicine

Kirkwood F. Adams, Jr., MDKirkwood F. Adams, Jr., MD

University of RochesterUniversity of Rochester John Bisognano, MDJohn Bisognano, MD

University of South FloridaUniversity of South Florida Douglas D. Schocken, MDDouglas D. Schocken, MD

University of Texas Southwest Medical University of Texas Southwest Medical CenterCenter

Clyde Yancy, MDClyde Yancy, MD

University of Washington Medical CenterUniversity of Washington Medical Center Carol Buchter, MDCarol Buchter, MD

Washington UniversityWashington University Gregory Ewald, MDGregory Ewald, MD



Curriculum Authors

Kirkwood Adams, MD Mark Dunlap, MD Doug Schocken, MD Hector Ventura, MD Mandeep Mehra, MD Ron Oren, MD Ileana Piña, MD Lynne Wagoner, MD Clyde Yancy, MD Chris O'Connor, MD Maria Rosa Constanzo, MD Barry Greenberg, MD Reynolds Delgado, MD

Theresa Demarco, MD David DeNofrio, MD Kimberly Huck, ND, RN Kay Blum, PhD Ginger Conway, MSN, RN, CNP Srinivas Murali, MD Kimberly Huck, ND, RN Kay Blum, PhD Ginger Conway, MSN, RN, CNP



N-HeFT LIVE

Customized based on individual applications Customized based on individual applications One or two Day Training with PreceptorshipOne or two Day Training with Preceptorship

– Small group interdisciplinary medical team visits 1/29 Small group interdisciplinary medical team visits 1/29 expert host sites of choice expert host sites of choice

– Selected Topics based on identified learning needs of Selected Topics based on identified learning needs of teamteam

– Training applied to practiceTraining applied to practice Practice improvement goals determined at end of training and Practice improvement goals determined at end of training and

submitted in writingsubmitted in writing 30, 60, and 90 day follow up conference by host team30, 60, and 90 day follow up conference by host team

One day with patient panel, strategic planning One day with patient panel, strategic planning workshop, etc.workshop, etc.



N-HeFT Online

Website: nheft.orgWebsite: nheft.org Online Curriculum Online Curriculum AudienceAudience

– CardiologyCardiology– Primary Care Primary Care – Allied HealthAllied Health– Site Directors, Clinical Coordinators, FacultySite Directors, Clinical Coordinators, Faculty



Program Quality Evidenced-based curriculum-dissemination of best practiceEvidenced-based curriculum-dissemination of best practice

Created, monitored and updated by committee of leaders in the Created, monitored and updated by committee of leaders in the field of heart failurefield of heart failure

Host sites are selected as best practice models of careHost sites are selected as best practice models of care All syllabi created at Case for disbursal to host sites All syllabi created at Case for disbursal to host sites

Quality continuing educationQuality continuing education National Office at Case Western Reserve University: National Office at Case Western Reserve University:

– Program administration, coordination, documentation, and Program administration, coordination, documentation, and trainingtraining

AccreditationAccreditation– AMA CME creditAMA CME credit– Nursing creditNursing credit– Pharmacy creditPharmacy credit– American Academy of family PhysiciansAmerican Academy of family Physicians



Standardization of Training

Standardized Content and ProcessesStandardized Content and Processes

– Online curriculum developed by network authors for continuing Online curriculum developed by network authors for continuing education education

– Training process standardized for faculty and participants Training process standardized for faculty and participants – Detailed application for customized training reviewed at CaseDetailed application for customized training reviewed at Case– Case manages application, enrollment, training and follow upCase manages application, enrollment, training and follow up– Password-protected slides and forms posted on web for Password-protected slides and forms posted on web for

faculty faculty – Syllabus and supplemental materials prepared at CaseSyllabus and supplemental materials prepared at Case– Resources for Professionals: sample quality tools, patient Resources for Professionals: sample quality tools, patient

education, referenceseducation, references



Heart Failure Patient Advocate Mission

The heart Failure Advocate will provide The heart Failure Advocate will provide evidence-based care that has been evidence-based care that has been shown to improve the quality of life for shown to improve the quality of life for heart failure patientsheart failure patients



Expected outcomes

The HF Advocates will implement The HF Advocates will implement changes in their system to improve the changes in their system to improve the quality of care of their heart failure quality of care of their heart failure patients specifically in the area of patients specifically in the area of mortality and hospital readmissionsmortality and hospital readmissions



Partners for Quality in Training Co-InvestigatorsCo-Investigators

– Ileana PiIleana Piñña, MDa, MD– Bill Abraham, MDBill Abraham, MD– Margie Namie, RN, MPHMargie Namie, RN, MPH– Susan Bennett, RN, DNSSusan Bennett, RN, DNS– Robin Trupp, RNRobin Trupp, RN– Raha Mostajabi, ANPRaha Mostajabi, ANP– Lynn Barrow, RN, MBALynn Barrow, RN, MBA

N-HeFTN-HeFT OSUOSU GWTGGWTG



Role of the AdvocateImpact systems outcomesImpact systems outcomes

Promote and market best practice care internally Promote and market best practice care internally and externally and externally

Coordinate careCoordinate care– Start Discharge planning in ER Start Discharge planning in ER – Facilitate transfers, discharge, placement in Facilitate transfers, discharge, placement in

rehabrehab– Follow upFollow up

Improve performance and outcomes Improve performance and outcomes Educate providers, patients, families, and Educate providers, patients, families, and

caregiverscaregivers Monitor and Influence decision-making along Monitor and Influence decision-making along

continuum of care continuum of care



Advocate TrainingDay I Initial Training

8:30 AM8:30 AM Welcome and Welcome and Introductions Introductions

8:30 8:30 HF 101 HF 101 12:00 Lunch with HF staff12:00 Lunch with HF staff 12:30PM Disease Management 12:30PM Disease Management 1:30 In-patient preceptorship 1:30 In-patient preceptorship



Advocate TrainingDay 2

8:00 8:00 Discharge Planning Discharge Planning 9:009:00 Clinic preceptorshipClinic preceptorship 11:00 11:00 Self Care Self Care 11:45 11:45 Lunch with HF staff Lunch with HF staff 12:3012:30 Day in the Life of an AdvocateDay in the Life of an Advocate 2:00 2:00 Quality of Life Quality of Life 2:302:30 End of Life End of Life 3:30 3:30 Networking Networking 4:004:00 Data ManagementData Management



Advocate TrainingPhase II with Physician

Champion

Disease Management strategies through Disease Management strategies through the life cycle of heart failure, the life cycle of heart failure,

Conduct on-going Patient Education Conduct on-going Patient Education focusing on self-efficacyfocusing on self-efficacy

Setting up A HF Program: Setting up A HF Program: Managing ChangeManaging Change Effective CommunicationEffective Communication



Dissemination

CHP: HF Advocate CHP: HF Advocate 2 Advocates in Cincinnati 2 Advocates in Cincinnati May 22-23May 22-23

Advocate MentorsAdvocate Mentors



Training Summary Ongoing Ongoing Multi-faceted ManagementMulti-faceted Management

Chronic Disease with multiple co-morbiditiesChronic Disease with multiple co-morbidities Systems with many layers and playersSystems with many layers and players Data and documentation from many sourcesData and documentation from many sources Providers of care not connectedProviders of care not connected Patients and care givers –adherence to treatment planPatients and care givers –adherence to treatment plan Many roles and activities and too little timeMany roles and activities and too little time

RequirementsRequirements Organization’s commitment to provide tools and Organization’s commitment to provide tools and

resources for successresources for success Advocate’s commitment to be a change agent creating Advocate’s commitment to be a change agent creating

a powerful coalition for patient carea powerful coalition for patient care

nheft.org

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