Introduction
The purpose of the Bridge Project under the National Heart Failure training Program (NHeFT) (It Takes a Community: Creating a Bridge to Improved Healthcare Outcomes for Heart Failure) is to stimulate quality improvement for patients with heart failure, including quality of life, and to disseminate this model to various care settings through collaborative efforts. Our short term plan is to reduce the 30 day readmission rate at your institution. Our long term plan is to facilitate the development of interdisciplinary disease management programs along the continuum of care which will improve the health of older adults with heart failure and empower the staff that cares for them with education tailored to each care setting.
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We believe that the devastating downward trend of heart failure can be reversed through collaboration and education. By improving care in individual settings and working together to create standards of care and improve communication, we believe we can reverse the downward spiral. Before implementing an improvement plan, it is critical that a process map be constructed to target the areas where the rate limiting step/s exist that are affecting the desired outcome. In addition, these rate limiting steps may be the very ones that need intervention in the plan, do, see, and act cycle of quality improvement.
Although some of these questions pertain to the hospital setting, it is nonetheless important to understand the “patient’s journey†from hospitalizations to home or skilled nursing facility to home and finally to your group. The seamless transition is one of the keys to success in caring for this population. Therefore, although this program is intended to set up a heart failure program within your outpatient cardiology group, obtaining hospital information is important. The hospital would be wherever your population of patients is being admitted. It may be not just one hospital but 2 or 3. Much of this information can be obtained from public websites. Once you have identified those for us, we will obtain as much data as we can. Coupled to your answers, we will process map your system/s.
This survey aims to identify efforts that have been or are currently being implemented and to assess the needs of each hospital/practice system who do or do not have a structured heart failure program to assist in developing and implementing the heart failure disease management plan. Admissions process:
What information do you get for patients admitted to the hospital in a non-heart failure service when they are discharged? How do you know that you will be seeing these patients?
Who has access to the information concerning patients that you will be responsible for?
How are patients admitted (i.e. by phone, in person, by paperwork) to the hospitals where you practice?
What is the process and structure of admissions?
Who admits patients, i.e., where do the patients come from? Consider PCP, Cardiologists, nurses, ED or transfers.
Cardiologists that participate in this program will:
Use optimal medical therapy processes to keep patients out of the hospital, thereby improving morbidity.
Medication uptitration to goal levels as Guideline, evidenced-based care.
Actively participate and support the multi-disciplinary team in the care of the heart failure patients.
To use a hospitalization to actively uptitrate medical therapy beyond simply diuretic treatment.
Support actively the patient educational efforts of the heart failure team members directly to the patient
Reinforce the educational objectives of the total health care team including sodium dietary restriction, fluid restriction when necessary, increased activity and medication compliance.
Consideration and discussion of ICD implantation when, in spite of 3 months of optimal medical therapy including optimally titrated doses of beta blockade, the patient’s ventricular function has not improved >35%.
Consideration of biV pacing if patient remains symptomatic in spite of optimal medical therapy and has a wide QRS.
To support the outpatient performance measures in the entirety of the practice and team effort.
Protocol:
A managed care program dedicated for heart failure patients to improve symptoms, functional capacity, and reduce hospitalizations. A second objective of the program is to practice using Guideline evidenced-based care with a combination of optimal medical therapy, patient education, close followup and pro-active interventional care to keep patients at home. Protocols will be individualized according to patient diagnosis and prognosis.
Inclusion Criteria:
Patients with a diagnosis of heart failure (ICD code 402, 404 and 428) who have been admitted to the hospital for decompensated heart failure in the past year.
Patients with frequent admissions for decompensated heart failure
Patients with the diagnosis of heart failure who have been requiring escalating doses of diuretics.
Patients with heart failure who have not been tolerating uptitration of evidenced-based care, e.g., ACE inhibitors or beta blockers
Patients with heart failure who have had compliance issues with diet or medication
Exclusion criteria
Patients with end-stage renal disease and dialysis
Patients with a history of drug abuse as an etiology of heart failure
Patients with stable heart failure who have never been hospitalized, NYHA Class I and II.
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