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CLARION Interprofessional Case Competition “The Heart of the Matter”. Our Team. The Heart of the Matter: Chronic Heart Failure (CHF). 5.1 million. Our Purpose. To recognize and eliminate the gaps and failure points that prevent optimal heart failure care at WestPlan.

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Clarion interprofessional case competition the heart of the matter
CLARION Interprofessional Case Competition “The Heart of the Matter”



The heart of the matter chronic heart failure chf
The Heart of the Matter:Chronic Heart Failure (CHF)

5.1 million

Our Purpose

To recognize and eliminate the gaps and failure points that prevent optimal heart failure care at WestPlan


Chronic heart failure westplan
Chronic Heart Failure & WestPlan

  • 1,817 WestPlan members have CHF

  • 184 (10.2%) members participate in our Disease and Case Management Program


Insured by Medicare

Retired Mechanic

69 Years Old

Family History

Margie Reeves

Harlan Reeves

Smoking & Drinking

Robert & Lisa Reeves

Stressors

Sedentary Lifestyle

& Poor Diet


MI at home/placement

of stent/pacemaker

at Central Hospital

(7months ago)

Hospitalization for deteriorating

condition and admitted as an

inpatient to the transitional care

unit (2 weeks ago)

Development/dx

of DM II (12 years ago)

Poor handling of

CHF dx 14 mos. ago

Admitted only for

observation 3 weeks ago

…no Transitional Care

High BMI due

to poor lifestyle

Non-adherence to

cardiac medication regimen

Poor coordination of care for DM II and CHF

Margie and Lisa now physically unable to care for Harlan

Family History

of DM II

The system failed Harlan Reeves

Fragmented health records

Rejected palliative

care 7 months ago

Low health literacy

Unmanaged DM II

Continued smoking and

sedentary lifestyle

No regular medical

checkups

Never referred to Heart

Clinic or transferred to

Transitional Care

FH of heart disease

Smoking/drinking

to deal with stressors

Inadequate home care

Age/gender: 69 y/o M

Diabetic and Cardiac

Events in the 7 months

following MI/Rushed

to the ER (3 weeks ago)

Unhealthy Lifestyle

Development/dx

of Grade III CHF

(14 months ago)



Our recommendations
Our Recommendations

1. Achieve Advanced Certification in Heart Failure by The Joint Commission

2. Partner with the Dunnelly community to implement population health management

Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement


Recommendation 1 advanced certification in heart failure
Recommendation 1Advanced Certification in Heart Failure


Recommendation strategy
Recommendation Strategy

[ ] Joint Commission Core

Measures in Heart Failure

[ ] Joint Commission

requirements for Advanced

Certification in Heart Failure:

INPATIENT and OUTPATIENT

[ ] WestPlan considerations for

Standards of Care



Tactic 1 information technology
Tactic 1 : Information Technology

  • Existing EHR Clinical Decision Support Tool

    • Cardiac Care Checklist

    • CHF Risk Assessment Checklist

  • Oregon’s Health Information Exchange program (Care Accord)

    • Integrating health records from WestPlan and outside of WestPlan networks


Tactic 2 transition coordinators
Tactic 2: Transition Coordinators

  • Transform discharge planners into Transition Coordinators

  • Ensures smooth transition from hospital to next care setting

  • Follow-up by post-discharge day 7 & connect with Home Care and Hospice services

  • Goals to achieve:

    • 80% patient follow-up with PCP, cardiologist, or Heart Failure Clinic or other WestPlan Service

    • 100% of medications prescribed are filled at discharge with medication instructions understood by the patient

  • Reduce CHF readmissions by 15% within year 1


Tactic 3 medication management
Tactic 3: Medication Management

  • Medication Reconciliation

    • Obtaining medication histories

    • Reconciling patient’s home medications with updated medication action plans

    • Interdisciplinary effort

    • Improving medication safety across the continuum of care

      • Inpatient stays

      • Outpatient appointments

      • Updated personal patient medication lists


Tactic 3 medication management1
Tactic 3: Medication Management

  • Medication Regimen Dose Optimization

    • Adding a clinical pharmacist to the WestPlan Heart Failure Clinic to help optimize heart failure regimens in the most critical and complex patients

  • Medication Therapy Management (MTM)

    • Adding an MTM pharmacist to the Disease and Case Management Program to help improve medication safety for patients not regularly seen in the WestPlan Heart Failure Clinic


P4 home care and hospice
P4: Home Care and Hospice

  • Why is Home Care and Hospice important for CHF patients?

    • Quality of Life

    • Patient Safety

    • Reducing hospital re-admissions!

  • WestPlan’s Home Care and Hospice services are underutilized. Why?

    • Stigma

    • Access

  • Our current team:

  • Geriatricians, Nurse Practitioners, Nurses, Social Workers, Assisted Living

  • specialists (home aides), Chaplains

  • Which roles do we want to add or enhance?

    • Transition Coordinators

    • Dietician

    • Clinical pharmacist


P4 home care and hospice1
P4: Home Care and Hospice

How will our improved interdisciplinary team help CHF patients?


Recommendation 2 population health management
Recommendation 2Population Health Management


Population Health Management

  • Intensive Case & Disease Management

  • Chronic disease self-management

  • Increased enrollment through electronic medical records (EMR)

  • Health Coaching & Lifestyle Management

  • Coaching lifestyle choices

  • Programs for modifying risk factors

InformationTechnology

  • Health Education & Promotion

  • Raising health awareness

  • Health promotion programs

  • Community Partnerships

  • Incentives

  • Screening & Annual Visits

  • Outreach & Awareness

Health Risk Assessment

OUR COMMUNITY


Chf risk stratification

Risk Stratification

CHF RISK STRATIFICATION


Westplan community care a van
WestPlan Community Care-a-Van

  • Interdisciplinary Team (Allocated Part Time)

    • 1 Public Health Specialist (Epidemiologist)

    • 2 Registered Nurses

    • 1 Social Worker

  • Services provided

    • Blood Pressure and Blood Glucose Readings

    • BMI Assessments

    • Tobacco and Alcohol Use Assessments (ASSIST)

    • Individual Health Risk Assessments

    • Referrals to WestPlan providers

  • Care-a-Van operations

    would partner with the

    Million Hearts Campaign


Raising health awareness
Raising Health Awareness

  • WestPlan Community Care-a-Van

    • “Honoring Choices”

    • Onsite patient counseling

  • Health Education and Promotion

    • Classes on various health topics

    • Specialized for inpatients, outpatients, or the general public

  • Community Partnerships

    • Health Fairs

    • Engagement with community stakeholders


Recommendations
Recommendations

1. Achieve Advanced Certification in Heart Failure by The Joint Commission

2. Partner with the Dunnelly community to implement population health management

Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement




Care a van pro forma analysis
Care-a-Van Pro Forma Analysis



Harlan reeves

Hospitalization for deteriorating

condition and admitted as an

inpatient to the transitional care

unit (2 weeks ago)

Harlan Reeves

MI at home/placement

of stent/pacemaker

at Central Hospital

Development/dx

of DM II (12 years ago)

Poor handling of

CHF dx 14 mos. ago

Admitted only for

observation 3 weeks ago

…no Transitional Care

  • Community Care Partners

  • Health Promotion & Education

High BMI due

to poor lifestyle

  • Disease & Case Management

  • Home Care & Hospice

Non-adherence to

cardiac medication regimen

Margie and Lisa now physically unable to care for Harlan

Poor coordination of care for DM II and CHF

FH of DM II

The system failed Harlan Reeves

Rejected palliative

care 7 months ago

Lack of education

Unmanaged DM II

  • Health Coaching & Lifestyle Management

Continued smoking and

sedentary lifestyle

No regular medical

checkups

Never referred to Heart

Clinic or transferred to

Transitional Care

FH of heart disease

Smoking/drinking

to deal with stressors

Margie suffering from caregiver’s burden

Age/gender: 69 y/o M

Diabetic and Cardiac

Events in the 7 months

following MI/Rushed

to the ER (3 weeks ago)

Poor lifestyle management

Development/dx

of Grade III CHF

(14 months ago)



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