SummaryEssentia Health Heart and Vascular Center restructured outpatient care for heart failure patients by incorporating a combination of chronic care and disease management principles and providing home telemonitoring for high-risk patients. The program, which coordinates care for 1,400 patients in northern Minnesota and northern Wisconsin, has increased use of appropriate medications; improved outcomes and functional status; and reduced readmission rates, length of stay, and overall costs of care for the health system.
Moderate: The evidence consists of comparisons of key indicators before and after implementation of the program.
Developing OrganizationsEssentia Health Heart and Vascular Center
Essentia Health Heart and Vascular Center was formerly known as St. Mary’s Duluth Clinic.
Use By Other OrganizationsA similar model has been established in Billings, MT. Groups in Fort Wayne, IN, and New York and Pennsylvania expressed information in obtaining further information and interest in hiring Essentia Health Heart and Vascular Center as consultants to establish a similar model. In addition, Wakasha, WI; Tampa, FL; and an organization in Indiana have asked to visit their site to see the program first hand.
Date First Implemented1998
Problem AddressedCongestive heart failure (CHF) is a highly prevalent, costly condition that imposes a significant burden on those it affects; however, conventional CHF care tends to focus on acute rather than chronic management strategies, which has negative implications for both costs and quality of care.
- Highly prevalent and expensive: Nearly 5 million Americans have CHF, and approximately 550,000 new cases are diagnosed annually.1 The total annual cost of caring for CHF in the United States is more than $25 billion, with 60 percent associated with hospitalization.2 The costs of CHF hospitalizations typically exceed reimbursement, as the expenses associated with long length of stay quickly overwhelm the $6,000 average reimbursement provided by Medicare.3
- Current care is inadequate: Traditional care processes are not well structured to prevent acute episodes in those with CHF. Patients often fail to recognize the early signs of decompensation and neglect to seek timely help; at the same time, office-based primary care is typically incomplete with regard to CHF patient needs. As a result, patients frequently decompensate and require costly emergency department (ED) and/or inpatient care. Once hospitalized, the lack of thorough patient education before discharge increases the patient's odds of early readmission.4
Description of the Innovative ActivityEssentia Health Heart and Vascular Center monitors the health status of ambulatory CHF patients and coordinates their care through several protocols and systems that are designed to prevent decompensation, with the goal of averting ED visits and hospital admissions. The program, which currently coordinates care for more than 1,400 CHF patients, targets resources toward those at greatest risk, including the elderly and those with more severe (designated as class III or IV) CHF. Because Essentia Health Heart and Vascular Center is not a transplant center, a relationship with Mayo Clinic and the University of Minnesota was developed for heart transplant and left ventricular assist device referrals. Key elements of the program are as follows:
- Physician referral: The majority of patients are referred by the system's cardiologists, who recommend patients who have been hospitalized as a result of decompensated CHF. Primary care physicians (PCPs) also refer a significant number of patients. Some patients self-refer after hearing about the program by word-of-mouth.
- Program introduction: Program staff, including both nurse practitioners and physician assistants, often introduce themselves and explain the program to inpatients who are referred by their physicians during the hospitalization. In cases in which such an inperson introduction is not possible, staff members send an introductory letter to patients.
- Initial program visit: A nurse practitioner or physician assistant meets with every patient for approximately 2 hours within 5 to 7 days of discharge (when risk of readmission is greatest). During this visit, the staff member describes the program, educates the patient about CHF, and determines whether the patient is receiving appropriate care, including guideline-directed medications at appropriate dosages and a recent evaluation of left ventricular function.
- Specialist care: If a referred patient has never seen a cardiologist, the nurse practitioner or physician assistant provides a referral to a cardiologist for an evaluation. Mayo Clinic heart failure specialists travel to Duluth every other month to see transplant/left ventricular assist device referral patients for their initial visit. This saves the patients from traveling 5 hours to Rochester, MN, for the initial visit.
- Periodic office visits guided by established protocols: Patients come to the office within 5 to 7 days of hospital discharge. A protocol specifies that for the first year, patients are seen every 2 weeks for 8 weeks, and then every 3 months; patients continue to be seen every 3 months unless their condition warrants closer observation. Each full-time nurse practitioner and half-time registered nurse can manage roughly 300 CHF patients. At each visit, protocols are used to ensure that all evaluations and treatment are consistent with established national guidelines. During each visit, registered nurses provide formal education and counseling on appropriate diet, lifestyle, and medications, while nurse practitioner or physician assistants prescribe medications (e.g., beta blockers, angiotensin-converting enzyme inhibitors) and conduct medication titration according to evidence-based clinical guidelines. Patients see a cardiologist at least once a year, and more often if necessary.
- Between-visit telephone access: Registered nurses are available to field telephone calls from patients experiencing problems, thus facilitating prompt symptom assessment and resolution. Patients are brought into the clinic if necessary.
- Between-visit home telemonitoring for high-risk patients: Between office visits, a home telemonitoring scale monitors both weight and important symptoms for selected patients who are considered to be at high risk of decompensation. The program added the home telemonitoring component in early 1999 after nurses realized that telephone-based weight checks were time consuming and often inaccurate (because patients self-reported their weight). Patients weigh themselves every morning and respond to simple questions (stated audibly and shown visually on an electronic console screen in large print) related to symptom exacerbation. Weight data and responses are transmitted through the telephone line to the program's computers, which track the responses and provide graphical trend data on weight. The computer program triages the information and flags patients who are above or below their personalized weight alarm settings and/or whose responses indicate symptom exacerbation. Registered nurses can contact these patients and decide on further action, such as implementing a diuretic protocol.
- Video telehealth: Information provided in September 2012 indicates that this program now also provides video telehealth for patients in rural communities. This has enabled providers to see these patients more frequently. Patients present to their local clinic and are roomed with a local medical aide, who stays in the room for the duration of the video telehealth session. The telehealth equipment includes a stethoscope, allowing the offsite nurse practitioner to listen to heart and lungs remotely.
- Group support and education: These sessions, which were designed based on the recommendations of a focus group of CHF patients, provide periodic clinical presentations to patients. Support groups are held four times per year at the main campus and twice a year at the satellite clinics. The support groups are lead by CHF program staff. Topics covered include managing medications (taught by a pharmacist), grief support (led by a grief counselor), managing diet (led by a dietitian), and living with the disease (led by a life coach).
- Quarterly newsletter: Essentia Health Heart and Vascular Center produces a quarterly CHF newsletter that is sent to patients and PCPs.
Context of the InnovationEssentia Health is an integrated health system with 4 hospitals, 17 clinics, and 750 physicians and employees managing more than 400,000 patient visits each year in Minnesota, Wisconsin, North Dakota, and Idaho. The heart failure program was started in 1999 by two interventional cardiologists at St. Mary's Hospital, an Essentia Health facility. These cardiologists wanted to improve care for CHF patients but recognized that the traditional medical model was inefficient and did not permit sufficient time to adequately coordinate care for this complicated patient population. As a result, these cardiologists found that many CHF patients ended up being hospitalized for exacerbations that likely could have been avoided with more timely outpatient care. In addition, St. Mary's Hospital ended up absorbing the costs of many of these admissions, especially those involving Medicare patients; the average hospitalization for CHF costs St. Mary's Hospital between $11,000 and $15,000, whereas Medicare reimbursement is only a little more than $6,000.
ResultsThe heart failure program has resulted in markedly better adherence to appropriate use of medications; improved outcomes and functionality; lower readmission rates, length of stay, and costs; and incremental revenues. This success has prompted the opening of several additional satellite programs, including in Ashland, WI; Hayward, WI; Spooner, WI; Virginia, MN; International Falls, MN; Deer River, MN; Superior, WI; and Brainerd, MN. In addition, they built a program in Fargo, ND, with outreach provided to surrounding rural communities of Whapeton, ND; Jamestown, ND; and Detroit Lakes, MN.
Moderate: The evidence consists of comparisons of key indicators before and after implementation of the program.
- Better medication usage: Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and beta blockers (which collectively represent the mainstay of high-quality CHF treatment) are appropriately used on 95 to 98 percent of patients in the program, up significantly from 50 to 60 percent appropriate usage before the program.
- Improvements in ejection fraction rates: Approximately 55 percent of program participants have seen a significant improvement in their ejection fraction rate (the percent of the total amount of blood in the left ventricle that the ventricle pumps out with each heart beat) since entering the program.
- Improvements in 6-minute walk test: Between 50 and 60 percent of program participants improved their 6-minute walk score after 6 months of participating in the program.
- Reduced readmissions: Since the start of the program, the 6-month readmission rate has consistently been 3 to 4 percent, down from 20 to 25 percent before the program began (this latter figure is roughly in line with Minnesota State averages). The national average readmission rate is roughly 40 to 50 percent. Six-month readmission rates are even lower for the 200 patients who are monitored on the telescale, with rates of 2 percent in fiscal 2005, 0 percent in 2006, 1.5 percent in 2007, 2.0 percent in 2008, and 2.5 percent in 2009.
- Reduced length of stay: Length of stay is slightly lower for program participants than for nonparticipants (3.9 days vs. 4.2 days in fiscal 2007). Length of stay has been declining over time for both groups.
- Cost savings: A pilot study conducted in 2000 in conjunction with Blue Cross/Blue Shield of Minnesota found that the program saved $1.25 million on the care of 29 CHF patients over a 6-month period; savings stemmed from reduced hospital admissions (approximately $1 million) and ED visits (approximately $250,000). Based on financial analysis of the program in 2009, the program saved the hospital more than $1 million by cost avoidance. Ninety-two percent of the patients have Medicare coverage.
- Revenue generation: The program contributes approximately $1 million in net outpatient revenues annually to Essentia Health; revenue stems from billable laboratory tests, echocardiograms, electrocardiograms, 6-minute walk tests, and other services.
- Better use of cardiologist skill set: Because nurse practitioners, physician assistants, and registered nurses now handle most outpatient care for CHF patients, cardiologists have more time to provide consultations and/or be in the cardiac catheterization laboratory or the echocardiography laboratory, allowing them to use their skills more appropriately and generate additional revenue for the system.
Planning and Development ProcessKey steps in the planning and development process include the following:
- Preparation and planning: A project manager gathered data and analyzed costs for 6 months. Essentia Health then hired a nurse practitioner, who, in collaboration with cardiologists, spent 1 year reviewing literature, training staff, developing internal processes, and "selling" the idea internally.
- Identification of initial CHF population: Nurse practitioners completed a chart review to estimate how many CHF patients were currently being cared for by the health system. The nurse practitioners then asked the appropriate cardiologists for permission to contact their patients about participating in the program.
- Database development: The information technology (IT) department developed a database that could be used to track patient care and outcomes. Later, the health system adopted an electronic medical record, which is now used for tracking; furthermore, the electronic medical record allows clinicians to use office visit template formats so that information can be gathered consistently across patients.
- Protocol development: Protocols relating to the referral process, office-based care, and followup care were developed by the nurse practitioner following American Heart Association/American College of Cardiology guidelines for care of chronic heart failure, in conjunction with cardiologists, during the preparation and planning process.
- Staff training: Nurses were trained on how to conduct inperson and telephone-based patient consultations. Registered nurses received on-the-job training from experienced registered nurses. Essentia Health Heart and Vascular Center also enlisted the services of a life coach, who held training sessions on how to coach people.
- Obtaining PCP support: A cardiologist "champion" contacted PCPs to explain the program and encourage referrals to it, emphasizing the program's potential to improve clinical quality and assuring physicians that the initiative would not undermine their control over patient care.
Resources Used and Skills Needed
- Staffing: Ongoing staffing includes a medical director (cardiologist) to provide clinical leadership and program oversight; cardiologists to ensure accurate diagnoses and treatment plans; nurse practitioners and physician assistants to provide disease management, medication management, referral for device therapy, and oversight of telescale data; registered nurses to provide patient education, manage telescale data, perform telephone triage, and track test and laboratory data; and administrative support staff. As noted earlier, one full-time nurse practitioner and one half-time registered nurse can manage roughly 300 CHF patients. Initially, the Essentia Health Heart and Vascular Center program included one nurse practitioner, one cardiologist, one registered nurse, and one certified medical assistant; current staff members include six nurse practitioners/physician assistants, two medical directors (cardiologists), six registered nurses, and three medical assistants. In addition to this ongoing staffing, the initial development of the database took about 100 hours of IT staff time.
- Equipment and other costs: The annual costs for the rental and fees associated with each home-monitoring device is $2,820 per patient. Other costs, such as production of the quarterly newsletter, are fairly minimal.
Funding SourcesEssentia Health Heart and Vascular Center
The hospital foundation provided funding to cover the costs of the telemonitoring scales for the first year. Once the program demonstrated improved outcomes for patients with scales, the cardiology section of Essentia Health assumed the cost of the scales along with other ongoing operational expenses. In 2009, Essentia Health Heart and Vascular Center contracted with third-party payers and passed on the cost of the scales and professional oversight to the payers. They now have contracts with several large insurance companies that include risk sharing for this population.
Tools and Other ResourcesClinical Practice Guidelines for Heart Failure include:
Watch related video from the Frontline Innovators series.
Getting Started with This Innovation
- Assess the costs of CHF to the organization, including whether current reimbursement levels are adequate to cover costs: As noted, Essentia Health Heart and Vascular Center was losing money on hospitalized CHF patients, largely because they were admitted in a highly decompensated state that required lengthy, costly stays.
- Consider both direct and indirect opportunities for revenue generation, as it may take time for the program to generate revenues on its own: Indirect opportunities include greater use of appropriate testing and more flexibility in cardiologists' schedules, which allows them to handle more complex cases.
- Set clear and specific goals for the program, with an initial focus on improving the provision of guideline-directed care: If this goal is achieved, other benefits will follow, such as decreased admission rates and ED visits. Additional goals can be added over time.
- Consider creating the program within the cardiology division/department: The creation of a separate entity may cause confusion about referral patterns and program ownership.
- Develop strategies for applying existing, accepted CHF guidelines: Such strategies include developing protocols for medication usage and titration.
- Consider starting the program on a small scale with a limited number of patients: Because patient counseling and education, particularly telephone consultations, can be time-consuming, it is important to ensure that staff can handle the initial number of program participants without becoming overwhelmed. Program size can be increased as existing staff prove their ability to handle larger caseloads and/or as more trained staff are added.
- Address PCP concerns about patient referral: Assure physicians that the program will improve care but not take control over the care of their patients.
- Assess the costs of 30-day readmission rates: Under Medicare guidelines, the care for heart failure patients readmitted with a diagnosis of heart failure within 30 days will not be reimbursed. Estimating the cost of 30-day readmissions can provide data to justify investment in the program.
Sustaining This Innovation
- Continually track outcomes to highlight the value of the program.
- Ensure that registered nurses are available to field telephone calls from patients who need ongoing education and/or quick access to help when they are experiencing symptoms.
- Conduct periodic group support and educational sessions for patients, and provide ongoing education via a quarterly newsletter or other means.
- Conduct ongoing internal marketing to medical/allied health staff.
- Reconsider cost of telescale. The cardiology department has covered the costs ($55/month/per patient on scale). After they did a 2008 financial analysis, their senior leadership decided it was worth the cost to continue to pay for the scales and not pass the cost to the individual patients. Instead, they contracted with three large insurance companies.
- Recognize that achieving a positive financial performance may take time.
Contact the InnovatorLinda Wick, NP
Manager, Heart Failure Program
Essentia Health Heart and Vascular Center
400 East 3rd Street
Duluth, MN 55805
Phone: (218) 786-3443
Innovator DisclosuresMs. Wick has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
2 Wick L. St. Mary's Duluth Clinic Heart Center Heart Failure Program. PowerPoint presentation. Accessed December 14, 2007.
3 Data provided by Linda Wick, Saint Mary's Duluth Clinic.
McAlister FA, Lawson FM, Teo KK, et al. A systematic review of randomized trials of disease management programs in heart failure. Am J Med. 2001;110(5):378-84. [PubMed]
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Original publication: April 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 23, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 05, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.