Effective Interventions & Processes

2. Effective Interventions & Processes Leading to High Performance in the Heart Failure Measures Eric Streicher, MD Judy Frisch, RN, MBA, CPHQ July 25, 2007

3. Overview • Demographics • HF measures • Guideline issues • Interventions • Outcomes • Summary

4. HF Demographics • Affects 4.9 million people • 550,000 new cases each year • Primarily a disease of the elderly • 12-15 million office visits • 6.5 million hospital days each year • Most common Medicare DRG • Total direct and indirect cost $27 billion in 2005

5. HF 1-Discharge Instructions • Educational intervention – 35% decrease in risk of hospitalization and death • Disease management program – improved functional capacity decreased hospitalizations

6. HF 2-LVF Assessment • Necessary for determination of eligibility for ACE inhibitor/ARB • Associated with increased use of ACE inhibitors and subsequent improved outcomes

7. HF 3-ACEI or ARB for LVSD • ACEI decrease morbidity and mortality • ARBs are acceptable if ACEI intolerant • Included in guidelines • Underutilized

8. Effect of Enalapril • Mortality reduction of 40% at 6 months, 31% at one year • Mortality effect in patients with progressive heart failure • No decrease in sudden cardiac death • Decrease in heart size, decrease in need for other medications • Improvement in functional status NEJM 1991; 325:293-302

9. Effect of Candesartan • Chronic HF • Decreased cardiac deaths • Decreased hospitalization The Lancet 2003; 362:759-766.

10. HF 4-Adult Smoking Cessation Advice/Counseling • No trials to specifically assess this in HF patients • Guideline derived from expert opinion • Validated in patients after MI

16. Why aren’t guidelines followed?

17. Cabana et al • Knowledge • Attitudes • Behavior JAMA. 1999; 282:1458-1465

18. Knowledge • Lack of familiarity • Lack of awareness JAMA. 1999; 282:1458-1465

19. Attitudes • Lack of agreement with specific guidelines • Lack of agreement with guidelines in general • Lack of outcome expectancy • Lack of self-efficacy • Lack of motivation/inertia of previous practice JAMA. 1999; 282:1458-1465

20. External Barriers • Patient factors • Guideline factors • Environmental factors JAMA. 1999; 282:1458-1465

21. Effective Interventions & Processes

22. Presentation Objectives • Identify gaps in the care process for heart failure patients • Describe effective interventions and processes to remove or decrease those gaps • Summarize commonalities across the success stories

23. Sources • The National Committee for Quality Assurance: www.ncqa.org • American Heart Association Heart Disease and Stroke Statistics-2003 Update. Dallas, Tex. American Heart Association 2002 • www.premierhealthcare.com • www.hfsa.org

24. HF 1-Discharge InstructionsCommon Gaps • Consistent education for patients with HF • Instructions for intensive monitoring of symptoms • Secondary diagnosis confusion • Patient compliance

25. HF 1-Discharge InstructionsEffective Interventions/Processes • For consistent heart failure education • Specified units for admission placement • Nursing knowledge of secondary diagnoses • EMR capabilities to track and support HF management • Grouping similar diagnoses • Discharge units • Order set, care maps and care pathways

26. HF 1-Discharge InstructionsEffective Interventions/Processes • For intensive monitoring of symptoms • Interactive activities with high risk HF patients (referral for telemonitoring after discharge) • ICU/Telemetry Nurse telephonic follow-up • Case management • Dedicated hospital heart failure educator

27. HF 1-Discharge InstructionsEffective Interventions/Processes • For patient compliance • Hospital nurse call back systems • Telemonitoring capabilities • Involvement of family and/or significant other

28. HF 2-LVF AssessmentCommon Gaps • Readily available LVF assessment results • Timely feedback regarding physician outlier data • Documentation by physician of the LVF test results

29. HF 2-LVF Assessment Effective Interventions/Processes • Nursing orders for LVF assessment • EMR capabilities for rapid recovery of test results • Collaboration with the clinics • Physician education related to the clinical practice guidelines • Order sets, care maps and care pathways • Hospitalist programs

30. HF 3-ACEI or ARB for LVSDCommon Gaps • Under utilization of ACE Inhibitors or ARBs due to provider concerns about • Hypotension • Renal impairment • Mismatch of heart failure medications from admission to discharge • Lack of documentation of LVF test results

31. HF 3-ACEI or ARB for LVSDEffective Interventions/Processes • Interventions and process steps to use ACEI or ARB for heart failure patients are • Power of medication reconciliation • Pharmacist programs • Order sets, care maps and care pathways • Incorporation of heart failure CPOE into EMR system • Standardization of the placement of discharge medication lists in the chart

32. HF 4-Adult Smoking Cessation Advice/Counseling – Common Gap • Assessment completed, yet often the counseling is not done or documented • Lack of consistent process for smoking cessation education

33. HF 4-Adult Smoking Cessation Advice/Counseling • Dedicated health promotion specialist • Counsels and offers smoking cessation tips • Enrolls in outpatient services • Pharmacy programs • Initiation of a physician and staff champions • Nursing admission assessment contains question and counseling

34. Commonalities Across Success Stories • Key elements of successful strategies • Developing the right culture for quality to flourish • Attracting and retaining the right people to promote quality • Devising and updating the right processes for quality improvement • Giving staff the right tools • Implemented performance incentives for contracted and for organization employees for job well done • Data sharing at many different places

35. Commonalities Across Success Stories • Multiple effective interventions and adjustments in response to data • Data profiling • Understanding of current process • Identification of the gaps for resolution • Hospitalist practice linked with core measures • Order sets required

36. Commonalities Across Success Stories • Computer-based physician reminder systems • Facilitated relay of data from outpatient to inpatient data

37. What about outcomes?

38. Measures vs. Outcomes • 5,900 patients hospitalized with HF • 60-90 day follow-up after discharge • Process-outcome relationship for performance measures Fonarow, et al, JAMA. 2007;297:61-70

39. Measures vs. Outcomes • Discharge instructions – no • Evaluation of LVS function – no • ACEI/ARB for LVS dysfunction – yes • Smoking cessation counseling – no • Warfarin for atrial fibrillation – no • Beta-blocker at discharge – yes Fonarow, et al, JAMA. 2007;297:61-70

40. Contact Information: MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320 www.metastar.com estreich@metastar.com jfrisch@metastar.com This material was prepared by MetaStar under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-WI-INP-07-103