Chronic America: Heart Teams Reinvent Old Systems to Improve Outcomes, Cut Costs
After decades of steady progress pushing back the leading cause of death and disability, cardiologists are striving to achieve the Quadruple Aim as they prepare for a tidal wave of aging patients with multiple chronic conditions. Bellwether hospitals are rethinking old systems and carving out new pathways for managing “Chronic America.”
Some eight years ago, the leaders of Banner Heart Hospital in Mesa, Ariz., saw the opportunity to create a new model of care for people with heart failure. They would disrupt the all-too-familiar cycle of treating these patients in the hospital and returning them home only to see them reappear in the ER days or weeks later. An apt goal, given that the healthcare community was abuzz about the Triple Aim, with policymakers determined to engineer reimbursement from volume to value and the government ready to penalize those who flouted the new order. What the 110-bed hospital did next, however, speaks volumes about how hospitals in America will likely have to reconfigure—even reinvent—themselves in the coming years to meet the extraordinary demands of a baby boomer–fueled deluge of patients with multiple morbidities and complex diseases. Banner engaged a team of process engineers to intricately map out how heart failure patients flowed through the system, not just in the hospital, but in the critical period following discharge when things can, and often do, go south.
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“We began to realize that the transition from hospital to home had lots of opportunities to improve care and prevent readmissions,” recalls Paul Hurst, MD, chief medical officer for Banner. “So, we adopted a continuum of care that basically swaddles the patient in a cocoon of supportive services designed to evaluate, educate and engage.” Since then, the institution has compiled one of the lowest 30-day rates of readmission for heart failure patients in the country, and made the list of community hospitals on Truven Health Analytics’ 2017 ranking of the top 50 cardiovascular hospitals.
Banner Heart Hospital is hardly alone in rethinking how it will meet the demands of caring for “Chronic America.” And not just for heart failure, but other complex conditions such as valvular heart disease, peripheral artery disease and congenital heart disease, plus a laundry list of secondary conditions—including falls, influenza, pneumonia and malnourishment—that also are likely to land cardiac patients back in the hospital in the weeks or months after discharge.
Awareness of the challenges and uncertainties ahead has given cardiovascular specialists little time to bask in the glow of what the field has achieved over the past 10 years. The national heart-related mortality rate declined at an average of 3.7 percent per year between 2000 and 2011, according to Cardiovascular Disease: A Costly Burden for America, a report issued this year by the American Heart Association (AHA) and the American Stroke Association (ASA). What’s more, public health prevention and control efforts have resulted in a 24 percent decline in U.S. cigarette consumption over the past 10 years. More recently, however, progress has stalled: in 2015 the death rate from heart disease grew by 1 percent, the first increase since 1969, according to the Centers for Disease Control and Prevention (CDC).
Even with cardiovascular innovators pumping out new therapies, there seems little chance of a near-term mortality rate reversal. Healthcare has already begun to hit the statistical wall of an aging population. Nearly 20 percent of the country will be 65 and older by 2030, and 19 million will be at least 85. And, according to the AHA and ASA, 90 percent of individuals over the age of 80 have some form of cardiovascular malady. Just as sobering, by 2035, the number of Americans with cardiac disorders is projected to soar to 131.2 million—45 percent of the total U.S. population. Already the country’s costliest disease, cardiovascular conditions will continue to exert an enormous economic as well as physical toll.
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Extending the support network
Aware of the landscape shifting under their feet, growing numbers of hospitals are breaking free of shopworn practices of the past and instituting aggressive new team-based approaches where the “team” is no longer just clinicians in hospital wings, but a host of supportive services and resources that stretches into the home and the community.
“You can’t close your eyes and think of the old ways anymore,” says Ann Mostofi, MSN, RN, NEA-BC, chief nursing officer and vice president for patient care services for Eisenhower Medical Center in Rancho Mirage, Calif., which, like Banner Heart Hospital, has achieved one of the lowest readmission rates for heart patients in the country. “We have to understand our mission and if that’s providing services to help people stay healthy and keep them out of the hospital, then we’re committed to being part of that.”
To see where this holistic movement is gaining traction, it’s not necessary to focus on the medical center mainstream in the largest cities. Rather, a coterie of smaller hospitals across the country with a strong financial stake in running smartly and efficiently have become exemplars of how integrating the most progressive practices can break the chain of repetitive hospital admissions for the chronically ill. At Banner Heart Hospital, for example, starting at admission, a multidisciplinary team is formed around each heart failure patient, including a bedside nurse, case manager, dietician, social worker and clinical nurse specialist who serves as both navigator and patient educator. Immediately, the team begins to plan for what will happen after the hospital, and paves the way by having patients begin to take their own medicines (which are delivered bedside prior to check-out) and weigh themselves while still hospital-bound.
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The patient education process that begins in the hospital doesn’t lose a beat afterwards. Home visits within the first couple of days by a healthcare professional and a dietician from the local medical school are coupled with a pharmacist-led medication management clinic that patients “are urged to attend.” Team members also weigh the need for remote monitoring of the highest risk patients with home video and motion sensors that check vital signs and activity levels. If the patient is referred instead to a skilled nursing facility after discharge, Banner defines care pathways and expectations for each patient, closely monitors the facility’s quality and performance data, and helps to ensure that each nurse has the skills and education needed to effectively care for the sickest heart patients.
“Forty percent of our patients tell us they don’t really know how to care for themselves at home, and that’s why our emphasis on education and engagement is so important,” explains Hurst. That instruction—spearheaded by nurse educators, dieticians and pharmacists—is aimed in no small way at family members and friends who can in turn encourage patients to take ownership of their wellness programs. “It’s when they start learning from peers how to get rid of high-sodium foods and shop for healthy replacements that things really start to click,” he adds.
New communication highways
While team-based care gains currency, it’s already a game-changer for hospitals most adept at controlling their readmission rates. Calling it the biggest change taking place in cardiovascular medicine, Mary Norine Walsh, MD, president of the American College of Cardiology (ACC), credits team-centered care with cutting back the silos that used to separate surgeons from cardiologists. “Now we make recommendations for patients as a team and actually perform procedures as a team,” says Walsh, who is director of the heart failure and cardiac transplantation programs and director of nuclear cardiology at St. Vincent Heart Center in Indianapolis.
No less profound has been the growth of patient portals allowing for quick and convenient back-and-forth between patient and team members via laptops, computers and smartphones. “Perhaps we’ll evolve to where we don’t even schedule in-person visits,” Walsh muses, “but have a system where a patient monitors his or her own symptoms and signs and reports them digitally or electronically to the doctor. Then we’d only have to see those patients with significant changes.”
Eisenhower Medical Center is adding a new lane to the digital highway. It is piloting a program for postdischarge patients that puts their medical plan and objectives online for family members—who may live on the opposite coast—to see and act on with members of the healthcare team if they notice, for example, that their loved one is having a health issue and could benefit from a caregiver visit that day. The program also makes it easy for the patient or family member to engage community-based resources to assist with grocery shopping or getting to the doctor’s office. “It’s not a medical model but a social services model that helps keep people as independent as possible using community resources,” explains Mostofi. “It also helps to keep them out of the hospital.”
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On the other side of the country, Lancaster General Hospital in Pennsylvania—which claimed the nation’s lowest 30-day readmission rate from heart failure (16.3 percent) based on Medicare data for 2012 through 2015—also is finding creative and practical ways to thwart patient readmissions. It provides a bountiful support system for the highest risk patients through constant telephone management after discharge, a same-day access clinic where they can get up to a full day of IV diuretics before returning home and a fully-staffed heart failure clinic that closely tracks and aggressively treats (sometimes several times a week) the sickest patients. In addition, the hospital maintains an ambulatory collaborative care team consisting of pharmacists, nurses, social workers and chaplains to provide in-home counseling, encouragement and support for patients. “Keeping people out of the hospital means good, aggressive outpatient management,” emphasizes Lisa D. Rathman, MSN, CRNP, CCRN, with The Heart Group of Lancaster General Health, part of the University of Pennsylvania Health System that includes Lancaster General Hospital, “and, if they have social issues, getting them linked up with the right care connections.”
Oklahoma Heart Hospital in Oklahoma City, which was designed by cardiologists, has also created expedient ways of treating patients with ischemic issues before they escalate into a trip to the emergency department. These include accessing one of the hospital’s 60 outpatient clinics throughout the state or a cardiovascular rapid response team nurse who answers questions round-the-clock and facilitates additional care, if necessary, through a network of other providers.
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Quality vs. length of life
Because the preponderance of treatment today involves the elderly, new healthcare models are raising fundamental questions around the appropriateness of that care if people are too frail to benefit from it. Put another way, should providing the best quality of life for the patient outweigh simply prolonging it?
“If you ask most elderly people who enter the hospital what they care about most they rarely mention anything medical,” says Daniel Forman, MD, professor of medicine in the division of cardiology and geriatric medicine at the University of Pittsburgh Medical Center and inaugural chair of the ACC’s Geriatric Cardiology Section. “They talk about wanting to be functional again, about wanting to go home and be active. Team-based is care helping to facilitate that by putting the emphasis on all aspects of function through exercise physiologists and physical therapists.”
Through its emphasis on relieving the symptom burden, palliative care is starting to figure more heavily in the new treatment calculus. Walsh points out that clinical members of cardiovascular teams routinely “help our patients make decisions about the quality of life and exactly what level of care they wish to receive.”
Lancaster General Hospital, for its part, is about to embed an outpatient palliative care physician in its heart failure clinic and already conducts advanced care planning with patients and their families on both inpatient and outpatient sides. “We could replace a heart valve but if the patient spends the rest of their days bedbound in a nursing home, it’s probably inappropriate,” acknowledges Justin Roberts, MD, director of The Heart Group’s heart failure program at Lancaster General Health. “We have to respect the patient’s desires and goals and work with palliative care and the family to come up with the best plan of attack.”
Technology redefining culture
If baby boomers pose one of the biggest challenges for the healthcare system, they also represent one of its greatest opportunities in the decade ahead. They are more tech savvy than any previous generation and promise to use their digital skills to make e-medicine the chief agent for transformative change in cardiovascular medicine. The electronic channel between physician and patient that has opened in the past 10 years is just the tip of the iceberg. Telemedicine, mobile health and a trove of downloadable apps that allow people to monitor their health and react quickly to any changes are already here. It’s not hard to imagine an emergency medicine physician taking a phone from the pocket of a heart attack patient just wheeled in and using the embedded information on activity levels and health history to help make quick and informed decisions about treatment.
“As technology becomes more and more entwined in patient care,” says Hurst, “it’s going to be an interesting 10 years ahead.”