Heart Failure Disease Management Program At JBVAMC, Chicago

1. Heart Failure Disease Management Program At JBVAMC, Chicago

2. 200 bed acute care facility 4 Community Based Out-patient Clinics (CBOCs) 58,000 Veterans IN FY 2008 : 768 HF admissions� cost over $10 Million Readmissions occurrence: - 29 within 0 to 2 days - 121 within 30 days Length of stay: 0-1 days /115 admissions Jesse Brown VA Medical Center JBVAMC is a 200 acute bed facility with 4 community based clinics And serves roughly about58,000 veterans There were 768 HF admissions recorded for the year2008 and they cost over $ 10 M 29 readmissions occurred within 0 to 2 days of discharge And 121 readmissions occurred within 0 to 2 days of discharge 115 readmissions had 0-1 days Los that could have been potentially avoided with out-pt care JBVAMC is a 200 acute bed facility with 4 community based clinics And serves roughly about58,000 veterans There were 768 HF admissions recorded for the year2008 and they cost over $ 10 M 29 readmissions occurred within 0 to 2 days of discharge And 121 readmissions occurred within 0 to 2 days of discharge 115 readmissions had 0-1 days Los that could have been potentially avoided with out-pt care

3. Problem Statement JBVAMC lacks a comprehensive heart failure disease management program (HFDMP) to meet the needs of veterans diagnosed with chronic heart failure. JBVAMC does not have a HFDMP The current pattern of care promotes episodic symptom relief, not disease managentJBVAMC does not have a HFDMP The current pattern of care promotes episodic symptom relief, not disease managent

4. Challenges: Heart Failure Resource Utilization There are multiple resources available at JBVAMC to help patients However they are not successful at disease management Mostly target episodic care No communication between the programs, however are meeting individual performance measures targets There are multiple resources available at JBVAMC to help patients However they are not successful at disease management Mostly target episodic care No communication between the programs, however are meeting individual performance measures targets

5. Overall goal is to develop an Advanced Practice Nurse (APN) led comprehensive HFDMP to provide patient centered care through the continuum. Purpose of this DNP project is to implement a sustainable nurse practitioner led HFDM clinic To Improve self-efficacy to reduce readmissions, improving quality of life, & functional status Ultimate goal is to develop a HFDM model that can be replicated at other VAs with similar resources and patient population. Overall goal is to develop an Advanced Practice Nurse (APN) led comprehensive HFDMP to provide patient centered care through the continuum. Purpose of this DNP project is to implement a sustainable nurse practitioner led HFDM clinic To Improve self-efficacy to reduce readmissions, improving quality of life, & functional status Ultimate goal is to develop a HFDM model that can be replicated at other VAs with similar resources and patient population.

6. HFDM programs reduced readmissions and hospital LOS improved health outcomes Improved self-efficacy, better quality of life, and function, greater patient satisfaction reduced healthcare costs (Krumholtz, et.al., 2006, McAlister, et.al. 2001, Watts, et.al, 2009 , Sochalski, 2009). HFDM Out-patient clinic critical to success of HFDMP (Philips, Singa, et,al., 2005). In clinic person communication program achieved better results than tele-management program alone (Sochalski, 2009) Successful HFDM programs included : clinic follow-ups, telephonic program, and in-house follow-up by nurse practitioner (Kwok, et.al., 2008, McAlister, et.al, 2001, Naylor, et.al., 1999; ). Reduced readmissions by 2.5%, and length of stay by 5.7% (Kwok, et al, 2008, Watts, et.al 2009) Why HFDM program ? Review of literature showed that HFDMP are very successful in improving self efficacy, reducing readm and LOS Out-pt clinic s are critical to success, especially if they follow pts within 7 days of hospital dischargeReview of literature showed that HFDMP are very successful in improving self efficacy, reducing readm and LOS Out-pt clinic s are critical to success, especially if they follow pts within 7 days of hospital discharge

7. Opportunities Executive Leadership Support Chief of Cardiology and Chief of Medicine Support Electronic medical records Patient Administrative Services data base for QA/QI HF patients want it Providers want it Upcoming National QA/QI incentives / rewards to reduce HF readmission rates VA QUERI support National wave- health care reform JBVAMC signed for �H2H� initiative JBVAMC on magnet journey Strengths : everyone wants it National wave to reduce chronic care readmissions, and cut costs- especially in this economy & the fact that Medicare will run out of money in 2017 if this trend continues Most tax payer dollars will go to health care- currently 20% is going towards haelth care Strengths : everyone wants it National wave to reduce chronic care readmissions, and cut costs- especially in this economy & the fact that Medicare will run out of money in 2017 if this trend continues Most tax payer dollars will go to health care- currently 20% is going towards haelth care

8. Weaknesses Limited resources both personnel and financial In-patient recruitment Data tracking In-patient/ out-patient education Telephone follow-ups Weekend coverage Patients may go to ED Lack of infrastructure to launch full HFDM program Threats Cross over of patient enrollment between various programs Patient compliance may not improve due to socio-economic issue Complexity of HF disease and co-morbidities Poor patient support system

9. Assess need for HFDMP: June 2009 Review of Literature : June 2009 - March 2010 Approval for program obtained: December 2009 Chief of Medicine, Cardiology & Chief of nursing meetings : January �Feb 2010 - Developed Power Point presentation January -2010 Multidisciplinary HF Committee formed - Chief of Cardiology, Chief of Medicine, Associate Chief of Medicine, Chief of nursing, Associate chief of nursing, Tele-health team, Home health nurse manager, Pharmacist, Cardiology nurse manager, Performance measures team, magnet coordinator, clinical nurse leaders, Hospitalist, CPRS team, Patient educator, psychologist, dietitian. VA Quality Enhancement Research Institute (VA QUERI) meetings : Once every 2 months Process Objectives #1: Obtain input and support from key stakeholders in organization - Completed

10. Collaborative Cardiologist Commitment obtained & Collaborative agreement signed: December 2009 Space & equipment commitment obtained :March 2010 Educational materials for the HF program being developed: May 2010 Clinic protocol developed and signed: May 2010 Electronic Consult set up � done- but will implement June 30th Tools: -decided Seattle risk stratification Tool , Riegel�s self efficacy tool , Quality of Life Questionnaire, & 6- minute walk test In-patient Staff training for patient Education � June 2010 Process Objectives #2: Laying the ground work for clinic (DNP project)

11. Start Clinic: July 1, 2010 Activate Consult: June 30, 2010 Recruit in-patients with HF diagnosis : June 30, 2010 Start discharge education (by RN) at time of hospital admission: June 30, 2010 Flag HF charts and patient rooms to alert providers: June, 2010 Start data collection using electronic medical records: July 1, 2010 Stakeholder meeting every month for program input Revisions to program based on team input and quarterly data analysis. Process Objective #3: Clinic Implementation - Start July 1, 2010

12. Improved self-efficacy Improved quality of life Increased functional capacity Reduction in 30 day readmission rates Decreased hospital Length of stay Decreased overall cost of care  Proposed Outcome Measures:  for the HFDMP clinic (DNP project) 

13. Questions ?