Ravi Ramani, MD

UPMC Heart Failure Care Delivery Initiatives

NCHS Data Brief No. 231, December 2015

Heart Failure: A Serious Problem

Trends in Hospital Readmissions for Four High-Volume

Conditions, 2009-2013. HCUP Nov 2015

Heart Failure: Current Clinical CareUncoordinated, reactive, fragmented, expensive

Well

ness

Time

Presentation “Stability” Decline Exacerbations Advanced Stage

Cost

Quality

Patients and ProvidersTreat the sick

Payers

Maintain Health

Incentives

FY 2015

Outcomes30%

Process Measures

20%

HCAHPS 30%

Efficiency 20%

CMS Hospital P4P –VBP Patient Care Domain Weight Shift

FY 2013

Process Measures

70%

HCAHPS30%

FY 2014

Outcomes 25% Process

Measures

45%

HCAHPS 30%

FY 2016

Outcomes40%

Process Measures 10%

Patient Experience of

Care 25%

Efficiency 25%

Process Measures 5%

Outcomes 25%

Patient Experience & Care Coordination

25%

Efficiency and Cost Reduction

25%

Safety 20%

FY 2017

Clinical

Care 30%

Reimbursement Impact:

• FY13 – 1%

• FY14 – 1.25%

• FY15 – 1.50%

• FY16 – 1.75%

• FY17 – 2%

Process Measures 5%

Outcomes 25%

Patient Experience & Care Coordination

25%

Efficiency and Cost Reduction

25%

Safety 20%

FY 2017

Clinical Care 30%

CMS Hospital P4P – VBP FY17

1 AMI: -Fibrinolytic therapy w/in 30

minutes of arrival

1 IMMUNIZATION: Influenza

vaccine

1 Perinatal*: Elective delivery

Performance Period: 01/01/15 –

12/31/15

8 HCAHPS:- Nurse communication - Doctor communication

- Cleanliness / quietness - Responsiveness of hospital staff

- Pain management - Communication about medications

- Discharge Instructions - Overall rating

Performance Period: 01/01/15 – 12/31/15

Efficiency:Medicare Spending per

Beneficiary Performance Period:

01/01/15 – 12/31/15

An asterisk (*) indicates a newly adopted measure or domain for the Hospital VBP Program

PSI Composite: Pressure

Ulcer; Iatrogenic Pneumothorax;

Central Venous Catheter-related

Bloodstream Infections; Postop

Hip Fracture; Postop PE or DVT;

Postop Sepsis; Postop Wound

Dehiscence; Accidental

Puncture or Laceration

Performance Period: 01/01/15 –

12/31/15

Infections: CLABSI, CAUTI,

SSI for Colon & Abdominal

Hysterectomy, MRSA*, C-

difficile*

Performance Period: 01/01/15 –

12/31/15

3 Mortality:

30-Day AMI

30-Day HF

30-Day PN Performance Period: 10/01/13 –

06/30/15

• >5000 discharges per year with primary diagnosis

• >150000 patients

• 3rd most rural state

• ~6000 physicians dealing with Heart Failure

• Complex payer mix

• 21% 30 day readmission, but range from 11-34%

• Fee for service model…..

UPMC Heart Failure Landscape

“Lord, give me chastity, but not just yet”

Saint Augustine

So what does one do????

ADMISSIONS

READMISSIONS

LOS

FREQUENT

FLYERS

INCENTIVES

RISK ARRANGEMENTS

SUPPLY CHAIN

US NEWS

Well

ness

Time

Heart Failure: Ideal StateProactive, continuous, coordinated care

Presentation “Stability” Decline Exacerbations Advanced Stage

HF Remote

Monitoring Program

HF

Pathways

Provider Alignment

Po

pu

latio

n M

an

ag

em

en

t

Population

Identified

Claims DischargesEMR

Structured Data

Unstructured Data

Validation

Content Analytics

Heart Failure: Population Management

Challenge

• 27222 patients with HF saw an HVI physician in the past

year as outpatient

• 23% with HFrEF (EF<50%)

• 29% with no EF in past year

• Mean age: 69 years

• Mean EF: HFrEF: 31%

• Medication rates:

– Betablocker: 72%

– ACE or ARB: 70%

• 45% had at least 1 hospital visit in past year

• 1597 patients had more than 5 admissions

• Overall annual mortality was 18% in HFrEF patients

Heart Failure: Population Analysis

Population

Identified

Chronic Care

PathwayEnd of Life Pathway

Advanced Care

Pathway

Stratify

Population Stratification

Inpatient Pathway Outpatient Pathway

Well

ness

Time

Pathways for Heart Failure:Proactive, continuous, coordinated care

Presentation “Stability” Decline Exacerbations Advanced Stage

HF Inpatient Pathways• Evidence based

• Reduction in care variation

• Checklists for complete care

• Volume Overload:

– Any dyspnea: 89%

– Pulmonary vascular congestion: 74%

– Rales: 67%

– Edema: 65%

• Other causes:

– Pneumonia: 5%

– Renal Failure: 5%

– Other septicemia: 4%

HF Pathways: Why Do HF Patients Get Admitted?

So: How Do We Treat Acute HF?

• At the time of discharge:

– 50% of patients lose less than 5 lbs

– 20% lose no weight at all

– 5% gain weight

• UPMC Data (smaller cohort) is very similar

• 50% of discharged patients wait > 10 days to see a

provider

– Rates higher in minorities

How Do We Really Treat Acute HF?

• Aims:

– Standardize care

– Reduce practice variations

– Address readmissions and length of stay

• Inpatient: CERNER PowerPlan based

• Outpatient: Remote monitoring standing orders

• Offer decision support

• Developed with input from APPs, housestaff, hospitalists,

and cardiologists across HealthSystem

Heart Failure Pathways

•New or previously unexplained Wall Motion (LV or RV)

Abnormalities

•New Significant (>moderate ) valvular abnormality

•New Significant pulmonary hypertension (>moderate)

Warm and Wet (on Floor) DAY 1

Confirm Diagnosis

HISTORY

Symptoms: SOB (orthopnea, paroxysmal

nocturnal dyspnoea); Swelling (legs and

adominal) Fatigue (tiredness, exhaustion);

Angina; palpitations; syncope

Cardiovascular events

Coronary heart disease: (MI, cath, PCI, surgery)

Valvular disease or dysfunction

Pulmonary Hypertension

Rhythm Problems

Risk profile: Family history, smoking,

hyperlipidaemia, hypertension, diabetes

Decompensation Factors: Compliance with diet

and medications, recent d/c, PCR follow up,

recent med changes, OTC medications,

infection, drug/ETOH use

PHYSICAL EXAM

Appearance: Alertness, nutritional status,

weight

Pulse Rate, rhythm, and character

Blood pressure Systolic, diastolic, pulse

pressure

Fluid overload Jugular venous

pressure,peripheral edema (ankles and

sacrum), hepatomegaly, ascites , high

respiratory rate, Rales, Pleural effusion

Low Output State: Pallor, cool skin,

diaphoresis, cyanosis.

Cardiac Exam: Heart Apex displacement

Gallop rhythm, third heart sound, murmurs

suggesting valvular dysfunction

LABORATORY

-CBC, Chem-7, troponin, LFTs ,TSH, dig, and

BNP

-EKG (if not already done

-CXR (if not already done)

Confirm Warm and Wet

Identify and treat non

CHF pathology

History: Shortness of breath and/or volume

overload; fatigue, lightheadedness not

prominent.

Response To ER Therapy: Symptom

improvement, and urine output>100 cc/hour

Physical exam: BP at baseline, volume

overload, warm extremities.

Bloodwork: CBC, Chem-7, and BNP: H/H at

baseline, creatinine or BUN/creatinine ratio

within 30% of baseline, or normal. BNP>400

EKG (if not already done): HR<130, no

significant arrhythmias

CXR (if not already done): Congestion and/or

cardiomegaly

Known History of CHF

Cold and Wet Pathway

New Onset CHF Pathway

Known Systolic Heart

Failure

Known Diastolic Heart

Failure

Known Right Sided Heart

Failure

Known Valvular Failure

Decompensation Explainable By History /Physical

/Labs

No New Cardiac Abnormalities on History/Physical

Cardiac Anatomy Assessed within past 1 year

Echocardiogram

Known Systolic Heart

Failure

Known Diastolic Heart

Failure

Known Right Sided Heart

Failure

Known Valvular Failure

Focused Evaluation based

on new pathology (treat as

new onset CHF)

Checklist Documented For All

Goals

•Type of heart failure identified

•Evaluated for cause of exacerbation

•Evaluated hemodynamic class

•On appropriate medications

•Inappropriate medications

stopped/addressed

•Diuresis initiated and maintained

Medications:

-IV Access

-ACE/ARB: Home dose; if not on at home

start captopril 6.25 TID or Lisinopril 2.5

qD/qHS. If not, document why not

-BetaBlocker: Continue if on at home, at

home dose ; if not on at home document

why not

-IV diuretic at ER dose

-Aldosterone antagonist (consider use if K+

low, or if systolic/valvular heart failure).

Spironolcatone 12.5 qD

-Digoxin (variable)

-Warfarin if atrial fibrillation (hold if

indicated/procedure planned)

-Confirm no NSAIDs, calcium channel

-Potassium supplementation (Protocol OK)

-Magnesium supplementation

-DVT prophylaxis

-Bowel protocol

-O2 to keep saturation>92%

Nursing:

-Home medications reconciled

-Strict I/O documented.

-Daily weights

-Activity orders

-2 Gram Sodium diet

-2 L fluid restriction

-Vital signs q4-8h

-telemetry

-nursing assessment

Multidisciplinary Care:

-PT/OT

-Social Services

-Nutritional Services

-Smoking cessation

-Care Transition Coordinator

-CHF Education

-Discussion of precipitating factors

-Palliative care

-Code status/Advance directives

Not CHF

No

No

YE

S

YES

YE

S

No

YES

Other Specific Pathology

Effusion, infiltration, constriction,

restriction

General CHF Pathway AND

Disease Specific Pathway

Acute Coronary

SyndromeNo

ACS Pathway

YES

Heart Failure Inpatient Pathway

• Focus on diuresis– Recommendations on doses

– Sets lower BP hold parameters

– Offers guidelines on renal function parameters

– Titration recommendations

– Linked to Pathway flowchart showing protocols

• Guideline based recommendations for standard HF

medications

• Prechecked Orders

– Remote monitoring for all patients

– Standard consults (Rehab, diet)

• Additional standard subphases: K repletion, DM, lipids

Pathway Key Points

Well

ness

Time

Heart Failure: Remote MonitoringProactive, continuous, coordinated care

Presentation “Stability” Decline Exacerbations Advanced Stage

HF Remote

Monitoring Program

Daily Weights

Blood Pressure

Symptoms

Remote Monitoring: End User

Results: Outcomes 2013-2015

792 Total

TM

346

30 Day Readmission

(TM Group)

12.9%

30 Day Readmission

(Control Group)

19.3%

TM+HC

472

30 Day Readmission

(TM+HC)

4.9%

30 Day Readmission

(System Control)

20.7%

Daily Weights

Blood Pressure

Symptoms

Remote Monitoring: End User

Provider Engagement

EMR Integration

Business Unit Alignment

Funding

Vendor Support

Remote Monitoring: Under the hood

• All patients eligible,

regardless of payer

• 90 day program

• Managed by UPMC VNA

• Protocolized management

• Standing orders

• Ancillary services

• New toys

• Analytics

Remote Monitoring: Redesigned

Well

ness

Time

Heart Failure: Ideal StateProactive, continuous, coordinated care

Presentation “Stability” Decline Exacerbations Advanced Stage

Provider Alignment

Collaborative Care VideoConference

PUH

PASS

MCK

NW

Altoona

MercySHY

STM

Jamison

Horizon

Collaborative Care Videoconference

• Democratize knowledge

• Foster collegiality

• Increase appropriate referrals for HF/PH

• Decrease inappropriate referrals

• Improve communication between specialists

Collaborative Care Conference: Aims

• Case based learning

• Not a teleconsult

• Expert panel: CHF, pharmacists, and additional experts as

needed.

• Target audience: UPMC cardiologists, cardiology APPs,

cardiology RNs

• 7-8 AM every Friday

• 2-3 cases discussed

• Didactic session

• CMEs

Collaborative Care Conference: Features

• Average attendance: 60 clinicians per session

• Improved referrals into advanced Heart Failure and

Pulmonary Hypertension Programs

• Reduced “futile care” transfers

• Heightened awareness of specialized resources: RV

support, Pulmonary Embolism team, Shock Team

• Multidisciplinary decision making

• Significant cost savings through spread of best practices

Collaborative Care Conference: Outcomes

Soooooooooo

Change Cometh…..