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April 2013
Promoting the Spread of Health Care Innovations

AHRQ's Health Care Innovations Exchange held a Web event on Promoting the Spread of Health Care Innovations on April 9, 2013.
Participants

Host:

Mary P. Nix, MS, MT(ASCP) SBB, PMP, Health Scientist Administrator, AHRQ





Presenters:

Linda Wick, RN, CNP, Manager, Heart Failure Program, Essentia Health Heart and Vascular Center, Duluth, MN

Ms. Wick is a Nurse Practitioner who has led the Essentia Heart Failure Program for the past decade. Under her leadership, the Heart Failure program has spread to 3 states and 10 sites. By leveraging technology to give nurses the ability to assess patients’ status within their homes, and applying a chronic disease management model, the Essentia Heart Failure team has held readmission rates for heart failure to less than 5 percent for several years. The Heart Failure program was instrumental in demonstrating the accountable care organization (ACO) model and meeting the Institute for Healthcare Improvement’s (IHI) Triple Aim of improving the experience of care, improving the health of populations, and reducing per capita costs.

View the Essentia Heart Failure Program video.

Janell Moerer, MBA, Group Vice President for Strategy and Business Development, Centura Health’s Mountain North Denver Operating Group, Denver, CO

Ms. Moerer recently joined Centura Health bringing a wealth of business development and strategy experience gained through her work in several settings of care including ambulatory care, hospital, post-acute care, rehabilitation, and working within the insurance sector. For the past 12 years, she served as Vice President of Business Development, Innovation and Transformation for Via Christi Health, Kansas’ largest provider of health services with 14 hospitals and over 300 physicians.

Moderator:

Veronica Nieva, PhD, Vice President, Westat and Editor-in-Chief of the AHRQ Health Care Innovations Exchange

Dr. Nieva directs the AHRQ Health Care Innovations Exchange and serves as its Editor-in-Chief. As an organizational psychologist and Vice President at Westat, Dr. Nieva oversees a portfolio of research and dissemination projects at Westat focused on the improvement of health care safety and quality. Her work focuses on the translation of research into practice, the dissemination of evidence based health care innovations, and scale up and spread of health care improvement efforts.


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Jump to Slides:
Judi Consalvo 1 2 3 4 5 6 30
Veronica Nieva 7 8 21
Linda Wick 9 10 11 12 13 14 15 16 17 18 19 20
Janell Moerer 22 23 24 25 26 27 28 29

Slide 1



Promoting the Spread of Health Care Innovations

Web Seminar
April 9, 2013
Follow this event on Twitter Hashtag: #AHRQIX

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Slide 2



Using the Webcast Console and Submitting Questions

Image of attendee console with an arrow pointing to the box to type in questions and another arrow pointing to the Q&A widget.

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Slide 3



Accessing Presentations

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Slide 4



What is the Health Care Innovations Exchange?
  • Publicly accessible, searchable database of health policy and service delivery innovations
  • Searchable QualityTools
  • Successes and attempts
  • Innovators’ stories and lessons learned
  • Expert commentaries
  • Learning and networking opportunities
  • New content posted to the Web site every two weeks
  • Sign up at http://www.innovations.ahrq.gov under “Stay Connected”

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Slide 5



Innovations Exchange Web Event Series

Archived Event Materials
Available within two weeks under Events & Podcasts
at http://www.innovations.ahrq.gov

Next Events

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Slide 6



Today’s Event Moderator

Ronie Nieva, PhD
Vice President, Westat and Editor-in-Chief of the AHRQ Health Care Innovations Exchange

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Slide 7



Essentia Health

Linda Wick, RN, CNP
Manager, Heart Failure Program

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Slide 8



Respondent

Janell Moerer, MBA
Group Vice President, Strategy and Business Development, Centura Health

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Slide 9



Essentia Health Heart Failure Program
  • First visit 5-7 days after discharge
  • Cardiology oversight – once per year
  • Patients managed in clinic: 4-7 office visits the first year
  • Registered nurses do case management: use protocols, manage home telescale data, follow up on lab/test data, and triage phone calls

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Slide 10



Program Components
  • Coaching
  • Education
  • Support
  • Consistency of care provider
  • Immediate feedback on health choices
  • Prescheduled follow-up appointments
  • Relationship building with patient/family
  • Multidisciplinary team approach to care
  • Engaged/passionate staff

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Slide 11



Triple Aim
  • Outcomes
    -  Use of guideline directed medications/devices

    -  Total yearly admissions/30 day readmissions
  • Patient Satisfaction
  • Reduced Cost of Care
    -  Total yearly admissions/30 day readmissions

    -  Reduce duplication of testing

    -  Using the right provider at the right time for the right diagnosis

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Slide 12



Bubble with words: “Show me the money” inside.

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Slide 13



Readmission Rates

Image of a bar graph showing hospital readmission rates. The national average for all years (2005-2010) was 40; the rate for heart failure patients in 2005 was 6.6 , in 2006 was 2.8, 2007 was 3.1, 2008 was 3.5, 2009 was 2.9, and 2010 was 4.8; the rate for health failure patients in 2005 was 18.1, in 2006 was 20, 2007 was 18, 2008 was 11, 2009 was 10.9, and 2010 was 10.9.

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Slide 14



Essentia Health St. Mary’s Hospital Readmissions

Image of bar graphing showing Essentia Health St Mary’s Hospital readmission rates. In 2010 the national average was 25, all cause readmission at St. Mary’s was 30, and 5 for the heart failure program. In 2011 the national average was 25, all cause readmission at St. Mary’s was 15, and 5 for the heart failure program. In 2012 the national average was 25, all cause readmission at St. Mary’s was 21, and 7 for the heart failure program.

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Slide 15



“Times They are a Changing”
  • Essentia Health is an Accountable Care Organization
  • CMS Bundled Payments for Care Improvement Initiative
  • Primary care is using health care home model: stable Heart Failure Program patients discharged to primary care physician

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Slide 16



Challenges: Administrative Buy-In
  • Ongoing challenge of administrative buy-in
  • Dialog changed once organization became an Accountable Care Organization: risk/benefit
  • Demonstrate how model fits Triple Aim
  • Markets within the organization have different priorities
  • NCQA accreditation process fits model

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Slide 17



Challenges: Provider Buy-In
  • Progress with physician and provider buy in: show data on outcomes
  • Culture changing from physician- centered to patient-centered
  • Culture changing from individual provider-based to team-based care
  • Other chronic disease programs changing to Heart Failure Model within Essentia

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Slide 18



Challenges: Workforce
  • Sustaining workforce with potential nursing shortage
  • Clear staffing roles
  • Inclusion/exclusion criteria for patients
  • Using Telehealth technology

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Slide 19



Scale Up and Spread
  • Added Telehealth video visits to remote sites
  • Added program staff to neighborhood clinics
  • Developed interface with primary care case managers: shared care plan
  • Integrated home scale data into electronic medical records with options for coverage from other sites

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Slide 20



Closing Thoughts

If everything seems under control, you’re not going fast enough.
–Mario Andretti

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Slide 21



Respondent

Janell Moerer, MBA
Group Vice President, Strategy and Business Development, Centura Health

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Slide 22



Comments and Considerations
  • Continuity of leadership and passion for the service has assisted growth and adoption
  • Data beginning to reflect intended impact to new value equation

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Slide 23



Impact of Changing Environment
  • Transformation and disruption of the norm has accelerated adoption and scale
  • Fee-for-service payment to bundle/Accountable Care Organization
  • Change in value equation: outcomes/cost

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Slide 24



Shift to Team-Based Care
  • Emphasis on team-based care: patient-centered medical homes/health homes
  • Heart Failure Program and team are more “part of” the delivery vs. “separate from” due to emphasis on team-based care.

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Slide 25



Overarching Questions
  • Where does this program need to reside in the short term, mid-term, and long-term?
  • Who should “own” it? Accountability?
  • How are the physician champions engaged in development and adoption with peers?
  • How will guardrails for compliance within the delivery system be addressed?

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Slide 26



Key Considerations

How will the challenges and opportunities change due to the transformation of payment and care delivery?
  • Administrative buy-in
  • Physician adoption
  • Delivery system needs and composition
  • Data gathering to data aggregation and segmentation
  • New competitors

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Slide 27



Key Considerations

How will the challenges and opportunities change due to the transformation of payment and care delivery?
  • Administrative buy-in
  • Physician adoption
  • Delivery system needs and composition
  • Data gathering to data aggregation and segmentation
  • New competitors

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Slide 28



Bubble with words “show me the money” inside. Money is crossed out and replaced with value.

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Slide 29




Questions?

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Slide 30



The Innovations Exchange

Visit our Web site:
http://www.innovations.ahrq.gov/ and Scale Up and Spread Videos

Follow us on Twitter: #AHRQIX

Send us email info@innovations.ahrq.gov
Listen to the audio file (Flash player download External Web Site Policy)

Transcript

Mary Nix: Good afternoon, everyone. On behalf of the Agency for Healthcare Research and Quality, or AHRQ, I'd like to welcome you to our web event, entitled, "Promoting the Spread of Health Care Innovations." My name is Mary Nix and I am with AHRQ Center for Outcomes and Evidence. We're very excited about today's topic and with 534 registered for this event, glad to see that you share our enthusiasm.

Before we begin, I'd like to introduce you to our webcast console. Next slide, please. The console can be resized to fit your entire browser window. All the components on the console can be resized, moved, and minimized into the Menu doc at the bottom of the console. If the slides are advancing slowly, I'm going to continue and you'll catch up. If the slides are too small, click on the lower right-hand corner of the slide window and drag your mouse down to make it larger. Twitter functionality is available in the console for today's webcast. Feel free to participate using the hashtag #AHRQIX.

We're pleased to offer closed captioning on this web seminar. To access it, please click on the link called Closed Captioning that is on the lower right-hand of your screen view. After you click the link, a new window will display the captioning. I would also like to remind you that if you experience any technical problems, you may click on the Question Mark button at the bottom of the screen to access the Help Guide or click on the Q&A button at the bottom of your screen to contact us with your question. Our technical staff will work with you to resolve any issues.

The last 10-15 minutes of this web seminar is reserved for discussion based on questions that you submit. Questions may be submitted at any time during the presentation. Simply click on the Q&A button at the bottom of your screen, then type your question into the Q&A box and select Submit. We welcome your questions and comments on the upcoming presentation and look forward to an engaging dialogue that will promote the scale up and spread of health care innovation. Next slide, please.

Today's slides are available by clicking on the widget at the bottom of your screen that says Download Slides. This will generate a PDF version of the presentation that you can download and save. Next slide, please.

The presenter that you will hear from today is an innovator from AHRQ Health Care Innovations Exchange. For those of you who are new to the Innovations Exchange, I will take just a minute to give you an overview. AHRQ created the Innovations Exchange to speed the implementation of new and better ways of delivering health care. The Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about, and ultimately adopt tested innovations and tools suitable for a range of health care settings and populations.

The Innovations Exchange web site includes a searchable database of quality tools and service delivery and policy innovations. The Exchange also contains both innovation successes and attempts at innovation, innovator stories and lessons learned and expert commentary. To assist you in decision-making around these innovations, AHRQ also supports learning and networking opportunities such as web seminars like this one, Tweet chats and podcasts. We post new content to the website every two weeks on a range of topics and hope that you will sign up to stay connected with us if you have not done so already. Next slide, please.

We have a number of upcoming web events to share innovative health care strategies and promote the spread of innovation. Our next learning and networking event is on April 25, from 1:00 to 2:00 p.m., Eastern time, called, "Payment Models that Support Medical Homes and Accountable Care Organization Principles: Maryland's Experience." To register for this event or receive more information, please visit our web site at www.innovations.ahrq.gov. The web site also holds an archive of our past web events, podcasts and Tweet chats and we invite you to take a look and download materials that may be useful to you in your work. Next slide, please.

Let's turn to our agenda for today. It is my pleasure to introduce our moderator, Dr. Ronie Nieva. Dr. Nieva is an organizational psychologist and Vice President at Westat, and serves at the Project Director and Editor-in-Chief of ARHQ's Health Care Innovations Exchange and has done so now for a number of years. At Westat, Dr. Nieva oversees a portfolio of research and dissemination projects focused on the improvement of healthcare safety and quality. Her work focuses on the translation of research into practice, the dissemination of evidence-based health care innovations and scale-up and spread of health care improvement efforts. Ronie?

Ronie Nieva: Thank you, Mary. This is such a nice spring day. I am pleased to be moderating this web seminar to help promote the spread of health care innovations. Next slide, please.

Today, we will hearing from Innovations Exchange innovator Linda Wick of the Essentia Health Heart Failure Program. Linda Wick, an innovator on the Health Care Innovations Exchange, is a nurse practitioner who has led the Essentia Heart Failure Program for the past decade. Under her leadership, the Heart Failure Program has spread to three states and 10 sites. Ms. Wick previously participated in the Innovations Exchange Scale Up and Spread conference in May of 2011. Her participation led to the development of a video where she shared her experience in spreading the Essentia Heart Failure Program to allow us to begin exploring the issues related to bringing innovations to scale.

Janell Moerer of Centura Health is also on that video and is here today as a respondent to Linda's presentation. Ms. Moerer is the Group Vice President for Strategy and Business Development for Centura Health, Mountain North Denver Operating Group. She has recently joined Centura Health and brought with her a wealth of business development and strategy experience gained through her work in several settings of care, including ambulatory care, hospitals, post-acute care, rehab and working within the insurance sector. For the past 12 years before Centura, she served as Vice President of Business Development, Innovation and Transformation for Via Christi Health.

We are looking forward to seeing a portion of the video today and continuing the dialogue on how to bring innovations to scale with Linda and Janell. But first, I'll turn it over to Linda to start by giving us a bit of background on the innovative Essentia Heart Failure Program. Linda?

Linda Wick: Thank you, Ronie, and it's a pleasure and honor to be here today and have our program highlighted in this format, as well as to have a conversation with Janell. So, to give a high-level overview of our program, the Essentia Heart Failure Program has been in existence for about 13 years and we have basically followed the same model for the entirety of the program. We recognized early-on that patients are at highest risk for readmission in the first 5-7 days after discharge, so we get those patients post-discharge into our program soon after they leave the hospital.

We have cardiology oversight. The patients are seen by the cardiologist once a year and they are managed in the clinic by nurse practitioners and physician assistants in conjunction with RNs. Our protocol calls for four-to-seven office visits the first year, but we've tweaked that a little bit depending on what the patient's needs are and registered nurses are heavily involved in the case management of these patients, using protocols, managing home telescale data and following up on lab tests and triaging the phone calls that come in. Next slide, please.

The program components consist of several items. Coaching, I think, is the biggest one and letting patients know who to call, when to call and what to call for. In many of my conversations with patients that have been hospitalized for heart failure, it's clear that they recognized they were getting in trouble. They just weren't sure who to call.

Education, of course, is a big part of what we do. I think that one of the things I've learned in this program is that we don't just get to tell patients once how to do things or what to do and expect that they have it. I kind of look at the same approach we use with our children. You don't just tell them once not to smoke and expect that they're never going to do it. It's constant re-education.

We offer support. These patients are often elderly and have multiple other comorbidities that they need help in managing, although in the Heart Failure Program, we only manage heart failure. We make sure that those other comorbidities are being managed by their primary care provider. I think consistency of their care provider is a big reason for our success. These patients know who to call and they know us when they talk to us on the phone and they know that we know them, so they have that consistency.

They also get immediate feedback on health choices. I look at this kind of like when you're driving and you see a trooper behind you. You take your foot off the gas pedal. By having these patients monitored on home telescales, they know that they're going to have to weigh in every morning and they make different choices as to what they eat and whether they take their meds, knowing that when they weigh in, that's going to reflect on them and they'll get a phone call from one of our nurses.

We preschedule our follow-up appointments so that before they leave the clinic, they have their follow-up appointment made. That's so if they cancel or no-show for whatever reason, we can catch those patients and make sure they don't fall through the cracks.

A lot of our work is relationship building with patient and families to get that trust for them with us and to also let them know that we are here and not just for the patient, but also for the family as this illness affects not just the patients, but their community.

We have a multidisciplinary team approach to care. It's not just the nurses and the physicians. We include pharmacists. We include dieticians. We include cardiac rehab. We include home care. We include hospice. We include their care providers at the nursing homes or assisted-living facilities that they live in. It's a very multidisciplinary approach and I think one of the biggest reasons for our success is we have very engaged and passionate staff. Next slide, please.

The Heart Failure Program from the very beginning has really met the Triple Aim and when the Triple Aim is more in our vernacular now as part of ACOs, we've already been there for 13 years. We, from the very beginning, have tracked our outcomes, our patient satisfaction and our cost. So, the outcomes that we track are the use of guideline-directed medications and devices. We track total yearly admissions, as well as 30-day readmissions. We track patient satisfaction and we've reduced total cost of care by reducing those total yearly admissions and 30-day readmissions. We've reduced duplication of testing, which happens frequently in this population and we have the right provider providing the right care at the right time.

Often, I've noticed that this population is seen by multiple providers and each one kind of doing their own thing and there's no coordination of care or you have physicians doing stuff that nursing or nurse practitioners could be doing or vice-versa. You have nurses doing things that clerical workers could be doing. So, really looking at role clarification and who's the right provider to do the right thing for the patient. Next slide, please.

Show me the money. In this era of cost containment, our Heart Failure Program has been a great fit for cost containment. Next slide, please. As you look at the national six-month readmission rates for heart failure patients, you can see that in the yellow bar is the national admission rate. The pink bar is for patients at our hospital here in Duluth, St. Mary's Hospital that are not involved in our Heart Failure Program and then, the blue bar is patients that are in our Heart Failure Program. The readmission rates for six months from first admission to six months out and you can see that we decreased readmission very significantly for heart failure after heart failure. Next slide, please.

This slide shows all-cause readmission and 30-day readmission for patients in the Heart Failure Program, as well as national average. As you can see, our all-cause readmission rate can be as high as 30%. There's multiple reasons for that. These patients, as I said, have multiple comorbidities, not just heart failure, but as you can see, the Heart Failure Program also affects those all-cause readmissions and cause for readmission being heart failure is also very low.

With this, we're going to show the video where Janell and I first met at the AHRQ Scale Up and Spread event.

(Video playing)

Linda Wick: Oh, the times, they are a changing, as Bob Dylan crooned and he's a local Duluth boy where Essentia Health is. Since we did the video and since I first met Janell, Essentia Health has actually become an accountable care organization. We are also in the process of negotiating our contract to participate in the CMS bundled payment for care improvement initiative and of course, we included heart failure as one of those bundled payments.

We have also developed a health care home within primary care. That has really helped us move patients back to primary care out of the Heart Failure Program as previously we didn't feel like they had the resources within primary care to manage these patients, so we hung onto them forever. So, we've really been able to utilize primary care and the care coordination that happens there to take over the more stable heart failure patients. Next slide, please.

Along with accountable care organization changes, we've had a little bit easier time getting buy-in from administration as we've scaled up and spread our program. The conversation has really changed from showing cost avoidance to showing how we meet the Triple Aim as in accountable care.

We've demonstrated how this model fits the Triple Aim and because we are spread across three states, we have different market challenges within each one of our separate states. Part of that is the payment system. Part of that is different Medicaid payments and how those are determined and also different health plans in the different areas. So, again, that just adds to the complexity of what we do, but also makes my job fun. The NCQA accreditation is part of what we've done as an accountable care organization and this Heart Failure Program fits that model perfectly. Next slide, please.

I don't want to paint a rosy picture that everything is perfect. We still have continued challenges with physician and provider buy-in. What I have found is that physicians really like data and when we can show them data on outcomes that show less hospitalizations, better adherence to guidelines and actually we now have some mortality data that are very favorable, it makes it easier to get buy-in.

The other thing that I have demonstrated to them is that we're not replacing them. We're another part of their team. We're another team member for them to take better care of these complicated patients. The culture here at Essentia Health is really changing over the last couple of years from physician-centered to patient-centered. Again, if we're patient-centered, we need to do the best thing for the patient at every step of the way and this Heart Failure Program for the patients that have heart failure has demonstrated that.

We're also having some culture change from an individual provider taking care of everything to team-based care. Very difficult for a primary care that has been trained in the model of the buck stops with you to depend on their team members, but again, that takes time and it takes building trust. It certainly is happening within our world.

We're using our model with other chronic disease programs within Essentia, for example, the diabetes program, to have nurse practitioners and RNs use the chronic disease management model for these chronically-ill patients with follow-up with physicians on a periodic basis, versus having the physicians do the daily or weekly follow-ups. Next slide, please.

So, we do have, as we talked about in the video, Janell brought up the potential nursing shortage. We're a little bit isolated from that here in Duluth as we have three nursing schools right within our community and so, we here personally haven't experienced that nursing shortage. However, knowing that the other areas that Essentia goes to in Wisconsin and North Dakota have potential to have a nursing shortage, we have really looked at clarifying staff roles. As I talked about earlier, making sure that nurses are doing things that only nurses can do and that clerical people are doing stuff that they should be doing and making sure that physicians are doing stuff that only physicians are doing.

We've developed inclusion and exclusion criteria for patients, so that as patients come into the program, we get them up-to-speed on their drugs and their devices and all the education and if they're stable and if they meet criteria for discharge, we get them discharged back to primary care. That has really helped on-load some of the workload of our nurses because patients like all the attention they get in the Heart Failure Program and they want to stay in the program, whether they really need our services or not. So, we had to change our practice and also help patients understand that they are graduating; that's a good thing if we can graduate them back to primary care.

We've also started using telehealth technology to help manage our patients in the remote regions. Duluth, Minnesota is in northern Minnesota. We have a wide region within northern Minnesota, northern Wisconsin, that are somewhat remote and don't have specialty care available in those communities, so using televideo health to provide care to those patients so they don't have to travel and I don't have to have providers or nurses travel has really helped, as well, managing the population in the rural community. Next slide, please.

I guess I already spoke about the telehealth visits to remote sites. We also are in the process of putting program staff in our neighborhood family practice clinics so that we're embedded in primary care, versus siloed in cardiology. We've developed an interface with the primary care case managers, or health care home managers and we share a care plan, communicate frequently.

That has been great for our nurses here who felt in the past that they had to make sure everything else was taken care of and didn't have somebody to hand that off to within primary care. It's also been great for the primary care case managers because they're now able to identify patients that would benefit from the Heart Failure Program and get those patients referred into our Heart Failure Program.

One of our big IT successes this last year was integrating our home scale data into our electronic medical record so that anybody can access that scaled data and I've been getting feedback from the ER physicians telling me how useful that is. Next slide, please.

As we continue to grow and spread, I am going to end with a quote from Mario Andretti. "If everything seems under control, you're just not going fast enough," and believe me, with all the changes that are happening in health care and how our program has been highlighted with our own organization, it feels like change is never-ending and we need to just keep moving to keep up with all the changes coming down the pike. With that, I'd like to introduce Janell.

Ronie Nieva: Great. Thank you so much, Linda. This is Ronie again. I just wanted to remind everybody that you're invited to send in your questions now as we go along, so please don't wait until the end. We're going to be monitoring them and see what your questions are and we'll try to answer all of them at the end of the show. Now, it's my pleasure to reintroduce Janell, who as I mentioned before, is a veteran participant in the Innovations Exchange. Like Linda, Janell participated in the 2011 Scale Up and Spread conference as a respondent and I know that the group found her insights invaluable then. We are so excited to hear what she has to say now about the growth and changes to the program over the past two years. Without further ado, Janell.

Janell Moerer: Thank you, Ronie and it's been a great deal of fun getting a chance to reconnect with Linda and watch the exciting things in innovation that have occurred with the program. I would just let the audience know that while you're having a lovely spring day, Ronie, both Linda in Duluth and me in Denver, Colorado, are enjoying the more inclement weather of snow and freezing rain.

But looking on the sunny side of things, one of the things that I find very gratifying in talking with Linda and listening to the activity that's occurred, and frankly, the growth that she's had in just a very short period of time, is that I don't think we can underestimate the continuity of a leader, nor the passion that they have for a service, in being able to help it to grow and particularly when you are doing any kind of transformational development that is going to be disruptive to the status quo, I've seen this time and time again with innovations and care re-engineering or reverse engineering, whatever you want to call it.

But without that sustained leader who's got the insight, the passion, the vision, frankly the persistence -- and I think those are characteristics that Linda brings to the table -- I think a lesson we can all learn is that it takes that type of sustained leadership in order to move through the disruptive waves. It's not if you're going to encounter challenges. It's when and how and how you move through those. I think that it's gratifying to see, Linda, you're there and not only are you there, but you continue to innovate and your leadership continues to have a broader reach as your program grows.

I think the other observation is that you really are beginning to get the data. You've got the benefit of time and history and data to reflect about the intended impact that you wanted to have, so that even ahead of the curve of reimbursement changes, really focusing in on the patient care, looking for the right data to present so that it's information and it's powerful information.

I think about the fact that you added the all-cause review and that you've really listened to, it's obvious to me you're listened to your customers, if you will, physicians and others, on what they need in order to help them see the value as they continue to deliver and provide care for the patients. So, I think you've listened well to understanding not only what data needs to be provided, but how you're going to present that and you're starting to have a very compelling story.

At the end of the day, it's still unclear about the overall financial impact, but I think one observation we can say that clearly, it's been the right thing to do, especially as you start to have impact on mortality rates. Next slide, please.

As it relates to the impact of your changing environment, it sounds like the theory that we've had that if you start to change the reimbursement model or the way that the incentives are addressed or not, that your ability to accelerate your program and begin to scale it really has come about as you start your organization and frankly, your market moves from the traditional fee-for-service payment to bundled and accountable care. So, your theory is proving out.

Many of us who are also, for instance, Centura, with whom I'm with now, moving into bundled payment, being part of an MSSP Accountable Care Program, were watching carefully as we continue to innovate on the heels of what you're doing at Essentia because again, we're looking. Does the value proposition in full-scale begin to prove out? So, it changes that value equation. You're starting to prove that. It's helping you adopt not only grow the program that you've got, but clearly as you start to see that scale into other chronic disease programs such as diabetes and being patterned off of your program, that's further indication that what you're doing is going to be catalytic and is seen as value.

I think a question I would have -- and I'd be curious to know over this newest change -- who has become your new fan and who have become your new naysayers because it's not a matter of whether or if you're going to have those that will continue to challenge your transformation and innovation, but I suspect the who has changed in that equation. Next slide, please. Did you have a comment?

Linda Wick: I was going to comment. I was going to say, our new fans are the administrators because it has allowed us not only to participate in accountable care and be NCQA-certified, etc., but we're also being approached by health plans that want to do bundled payments outside of the Medicare/Medicaid population. So, the administration in the past saw us more as a cost center. They're willing to do it because it's the right thing for the patient, and now, all of a sudden, they can't promote us enough because it's the new model of care.

The new naysayers, interestingly enough, are some of the nurses because they're having to give up some of these patients back to primary care and so, the ownership that goes along with, "I've taken care of this patient for six years and now you're asking me to give him back to primary care where they won't have me," has been very interesting for me as a nurse to watch that transformation. So, having to coach these nurses that, yes, they have to go back to primary care. They're stable. Their heart failure is stable. They don't need our intensive management that we provide here.

Janell Moerer: And I suspected, again, any time you go through transformational change, right, there's going to be sort of a natural shift in fans and foes, if you will, or challengers and opportunities. But let's continue that dialogue a little bit, Linda, because the other observation I had is again, shifting to team-based care -- so this will make the conversation interesting -- because the observation I had when we had an earlier conversation about this was that moving into that medical home or health home model and team-based care has become another accelerant for the adoption, scale and spread of your program.

So, instead of being seen as separate from, you're now really being grafted into that team-based delivery system. As we've just heard, that carries its positive because it's giving you more acceleration in the adoptability and receptivity of the program and into a broader whole of the delivery system. The unintended consequence is continuing to help work with your team, nurses, and probably others, in being able to be part of a broader group and graft it into a broader group.

Again, I think what would be interesting is -- that's how we're talking about it today -- feels like in the future, we might hear you start talking about not the Heart Failure Program, but about the ambulatory care delivery as a whole versus a singular program piece. To me, then, that would indicate that we've really grafted the program into a whole delivery component that's part of a system of care versus a singular program that can be grafted onto or off of the system. So, I think the more tightly you get grafted into that delivery system, I'd be interested to see what the conversations change. Next slide, please.

Because then that leads to some of the questions. I've listed a few of them here, Linda, and I'd like us to take -- actually even talking about that one. So, you've got nurses that have been in the Essentia heart program and they are now, after doing the good job, they have the privilege of seeing that their work benefits by having the patient go somewhere else under someone else's leadership or someone else's care delivery.

Let's take that first question. If you're looking at the program and really, if we think about how long-term sustainability -- and frankly acceleration -- is being really grafted into that care delivery wholly, where does this program need to reside in the short-term, mid-term and long-term? Have you had a chance to give that some thought?

Linda Wick: We have, actually. I think that there is, as people advance with their disease process, their needs change and so, the amount of care that they need changes. I still believe that the more critically ill heart failure patients that are in the Heart Failure Program, that that program needs to reside within cardiology because this is the cancer of cardiology, so to speak. The nurses and nurse practitioners need access to the cardiologists and the heart failure specialists to help us manage these very challenging patients.

Once they're stabilized and once we have things under control, if we're able to get them under control, and the patients are very stable, then I look at having these patients cared for in their neighborhood clinics, again, by nurse practitioners, but in conjunction with their other chronic disease programs that are being developed as we speak happening within primary care. You worry about -- some of the concern I've heard -- is, "Well, does it get diluted out?" Well, if they're stable, I'm much more comfortable having it be diluted out a little bit and making sure that their diabetes is well-managed, for example.

Long-term, maybe they stay within primary care and only come back to the cardiology clinic if they again decompensate or they again develop problems. But I think that's something we're grappling with because our program has been where it has been for such a long time, we're going through transformational change within the program as to how to meet the needs of the wider population.

Janell Moerer: And, as you look at meeting the needs of the wider population, Linda, are you finding that your reach gets -- what's happening with the reach that you have? Let's talk about we look at the question, "How are physicians champions, aid in the gauge and development and adoption with peers?" Let me put just a spin on that question. How are referrals changing or ways patients find you? How is that changing as patients find you coming into the program and are you finding being able to get access to those patients sooner, not later? Is that changing and have your referrals or who's referring changed?

Linda Wick: Good question and yes to all of those. The physician champions are very engaged in development. What's been fun for me is to have the primary care physicians be champions of this program. In the past, at the beginning of the program, the primary care physicians were very hesitant to hand over care to nurse practitioners within cardiology. They weren't sure what we were all about and we had to do lots of education and reassuring that we were only going to deal with heart failure.

Thirteen years later, these physicians are our biggest champions in getting patients enrolled into our program. So, we have seen a change from our patients getting referred only from the in-patient side once they hit the hospital with decompensated heart failure to the primary care physician saying, "Hey. You have heart failure. I need you to be in this program because they're going to help take care of you along with me." So, the physician champions unexpectedly have been primary care.

I think another thing that has happened as we've been kind of more vetted within the whole program -- especially with the bundled care initiative where we've worked on a process that from the time a patient hits the emergency room through hospitalization and discharge and then post-discharge into skilled nursing facilities or assisted-living facilities -- the ER physicians have really been champions. It's been really exciting for me to get calls from the ER saying, "Linda, I've got this patient down here. I don't think they need to be hospitalized, but somebody needs to follow up with them and so, tell me what you need me to do. Can you come see the patient? Can you set them up to see them?"

So, even though we have a process, they're not comfortable with the process yet. Instead of just writing orders and putting them in an EMR, they want to talk to me to make sure that yes, me or one of my colleagues is going to see these patients for follow-up. I'll run down to the ER, introduce ourselves. Talk to the patient about, "If you can come for follow-up tomorrow, you don't have to go to the hospital; be admitted into the hospital." So, that has been really exciting for me because that's been a vision I've had for a long time, to catch these patients before they hit the hospital if they don't actually need hospitalization, if they can be managed as an out-patient.

The adoption with peers is very different than it was 10-13 years ago. When we show our data now, the question is what more can we do, what more do you need, as opposed to, "I don't need the Heart Failure Program. I can do this myself." Very different conversation.

Janell Moerer: When you say, "Very different conversation," what's the most compelling thing for you that's happened? Let me also ask and what do you think still has yet to occur?

Linda Wick: I think showing that our readmission rate, being able to compare patients in the program versus patients that aren't in the program within our own system was compelling, that, "This is what you're doing without the program. This is what we're doing with the program." That was one thing that has gotten a lot of attention, as well as I've been starting to share our mortality data. We're still kind of fine-tuning that data and we're going to hopefully publish it, so I don't want to say too much about it, but there is a mortality benefit for patients being in the program.

The mantra I use is if we had a drug that did this, it would be unethical to not use it. So, I think that if you looked at the program and said, "We had a drug or device that did this, would it be adopted?" The answer is yes, with these outcomes. Why are you having a problem working with a team of nurses that can achieve these outcomes?

Janell Moerer: And that, again, I think hopefully you will begin to see that change if the theory continues to bear out with the way more emphasis on payment around prevention and in terms of payment around outcomes versus episodes. Can we go to the next slide, please?

Let's talk a little bit, Linda, I'd like to just begin to think now as you take the program -- because it's obvious that you've got a good momentum. You've got a good trajectory for really hard-wiring the program within the broader care delivery system. What I'd like to do is talk a little bit about what challenges or opportunities you think are going to change as transformation occurs.

We've already started talking a little bit about that, but as it relates to what the delivery system will need in the composition, what do you think new challenges and opportunities are you already beginning to think about within the context of becoming more firmly grounded in the ACO models, more firmly grounded in bundled models? If we were going to take what does the delivery system need and the composition of your program, what challenges and opportunities do you see facing you coming down the road?

Linda Wick: As you know, Janell, cost containment is going to continue to be a huge challenge and using providers appropriately. We still have the need to touch these patients and I think that we're going to have to rely more and more on technology as we move forward. Our telescales have been a perfect example of that where we only call those patients if they have an alarm, so that we're doing monitoring, but we're not calling them every day, so those efficiencies.

As you're probably aware, there's lots of apps coming out there for people to do monitoring at home and making patients more responsible for their care. What's interesting to me is that when we talk about the Medicare/Medicaid population, we often think that they're not very computer-savvy and that really hasn't been my experience. If they're not computer-savvy, they have children or grandchildren who are.

They've really embraced technology and so, communicating via email or maybe doing Skype-type visits in the home for those patients that can't get into the clinic, I think the bricks-and-mortar kind of healthcare buildings that we've all grown up with are going to be less and less a part of healthcare in the future. The more we can use technology to manage these patients, the more efficient we're going to be and the more cost-effective we're going to be. It's very scary for providers who have been trained in the, "I only care for somebody who's in front of me who I can touch," model.

For example, when we started doing telehealth with our remote regions, the cardiologists were very hesitant to believe that it was going to be a good thing. They were really worried about the risk of doing that from a legal standpoint. They thought patients would not like it and so, when we started telehealth, I had a nurse practitioner doctoral student that did her project on patient satisfaction. We showed that patient satisfaction was very high. They think it's very cool that they can be in Deer River or International Falls, Minnesota, and I'm in Duluth and we can see each other video. We have the stethoscope that I can hear their heart and lungs and they don't have to travel and I don't have to travel.

The other thing that it opened up for them was that I was much more accessible for them. If they were sick, I could see them that day versus, "Well, I don't come up there again for a month," when I was just doing outreach up there. Again, learning curves with using that technology and that patients do want to see you periodically, so that we've learned that we shouldn't just do only telehealth; that periodically, I do have to show up up there and see them face-to-face. But by and large, the telehealth experience using video visits has gone very, very well and again, people were afraid to use it. Now I have cardiologists asking me, "How come I don't get to do telehealth? When do I get to do that?"

Janell Moerer: You know you're onto something when you get that kind of a reaction. I'd like to go to the last slide and I know we want to be able to open it up to our audience. Can we go to the next slide, please? Maybe I can go to the previous one. Sorry about that.

You spoke right into what types of innovations are you going to need to have in mind to accelerate adoption and to sustain the value. I've listed some here. You've already talked about the iHeart Failure, an app for that. Talk to me a little bit about potential competitors, retail competitors. There's technology. The GDP doesn't seem to be shrinking and clearly our technology and retail colleagues, if you will, are finding their way into chronic disease management. Talk to me a little bit about you're looking at those kinds of opportunities or challenges and what your thoughts and reactions are or even if you've even begun to look at those.

Linda Wick: I haven't put a lot of thought into the retail competitors for heart failure, but I agree, Janell. I think they're out there. One of the things we saw in medicine with radiology is that you can send this stuff remotely to another country and have the radiology reports read and sent back in a minute or two. So, I'm under no illusion that that won't happen with chronic disease, especially as people are looking at cost containment and can you take this data and send it all around the world and have a nurse in Norway call the patient back or wherever. Absolutely, absolutely that needs to be on our radar and how do we make sure that those patients recognize the value we bring.

I think one of the things as we've looked at the chronic disease management programs within health plans and how we differentiate ourselves from them is that we have access to their electronic medical record and can see the whole picture, not just one piece of the pie. I think that we're just going to need to continue to use that opportunity of, "You get all your health care with us, not just your heart failure care," leverage that with patients. They're starting to see the benefit of having all their health care in one place where everybody can see the same medical record. I'm hearing that more and more from patients than I ever used to in the past.

Janell Moerer: This has been delightful to get a chance to reconnect with you. I'm thrilled about what you're doing. We will stay connected, Linda, and I'll look forward to future conversations. With that, Ronie, I'll hand it back to you and for our audience.

Linda Wick: Thank you, Janell.

Ronie Nieva: Thank you, both. What a fabulous discussion. We're so sorry. We're always running out of time, but we have a couple of nice questions here, some philosophical and some very practical. Let me start with the practical ones where I know various of you in the audience have asked questions about cost. That's always the "show me the money" question.

Let me say, "How are you paying for the Heart Failure Program, telemonitoring? Just exactly how does the bundled payment system work for you?" I guess that's a question for you, Linda. I guess a related one on the other side is about cost savings. "You mentioned cost savings from reduced readmissions and ED visits. Can you talk a little bit more about that and other aspects related to costs and payments?"

Linda Wick: Sure. From the very beginning, the cost of our program has come out of our cardiology department. The NP and PA visits with patients in the clinic are billed as a established in a level IV or V, just like any other visit would be in the clinic. The nursing care, of course, the telephone triaging and the education and such that's done with the nurses, that has been the biggest black hole because there's no fee or bill I can send out for my nurses' time.

Now with the bundled payments, we're able to say, "This is our total cost of care for 90 days." We're able to bill that cost of the nursing care in, because in the past, the cost of these patients, if we failed at taking care of them, if they hit the ER or they hit the hospital, we got paid for that in fee-for-service world. Now we're not and so, in the past, even though we had low readmission rates, it was the health plans, it was Medicare that benefited, not us. We were absorbing the cost, but they were benefiting.

One study we did showed that we saved a health plan $1.25 million in six months on 25 patients. Again, it was all cost control from keeping them out of the hospital and out of the ER. So, we're able to show that by keeping them out of the hospital and out of the ER, that is very cost-effective. It's much more cost-effective to pay for an RN's time on the phone or face-to-face doing education with these patients versus having them hit the ER.

The telescales have been paid for out of cardiology, again, from the very beginning. We were very, very lucky that we had an administrative and cardiologist leader who was very passionate about doing the right thing for patients. So, we have absorbed that cost within cardiology. Now, with our contracts with third-party payers and with the bundled payment plan, we just build the cost of those scales into those payments, but we do not bill patients for those.

Ronie Nieva: Thank you. Here's another question that's shared by a lot of the questions that have come in, which focuses on the integration between the Heart Failure staff and the primary care staff. Just how did this integration occur and what would you advise other systems that are trying to work this same integration between specialty care, basically, and primary care?

Linda Wick: That's an excellent question. I will say at the beginning, we made a lot of mistakes. We should have included primary care at the table from the very beginning when we were developing the program. We didn't. We just included the cardiologists and the nurse practitioners within cardiology and then went out and told everybody how good we were and that they should send us their patient. You can imagine how well that went over. We learned a lot from that.

So, we now bring in internal medicine or family practice slowly over the years. This isn't something that we did once and then we had it fixed. Over the years, we started bringing them into our meetings, asking for their input. Going out to our regional family practice clinics and asking them what we do well, what we could improve on. So, we did that for a period of probably five or six years, just really reaching out to them, asking them for their feedback and then, sharing our data with them.

That was one of the things I realized, that our data was siloed, as well. Our administration knew it and our cardiology department knew it, but nobody was sharing it with primary care, so sharing that data with primary care. As Essentia Health grew and became an integrated health service or healthcare organization, one of the things that we did was develop leaders across Essentia for different -- like for primary care, for example and for heart and vascular.

When that happens, when the primary care had a leader that went all across Essentia, that made my job a lot easier. I could communicate with that person, share our data, share our challenges. He or she brings that back to the primary care departments across Essentia. They've had me speak at their meetings. It's been much more interactive after we had somebody that went across all of Essentia versus this city, this city, this city. It was much more isolated and difficult to communicate until we had a common platform.

Janell Moerer: Linda, can I just ask a question since you're on that because I was really struck by the fact that the new sort of naysayers are even some of your own staff where they have to do the handoff back to primary care. I listen carefully because I think we will all face that unless there are the lessons learned of engaging primary care sooner. Has that helped when you started to engage primary care and even the primary care staff, you share a common care plan? Has that helped create a stronger bridge for the staff?

Linda Wick: Absolutely. I've worked hard to bring those care coordinators from primary care into our meetings and vice-versa. I have a couple of our nurses that work in the Heart Failure Program attend their meetings so that we're sharing information back and forth and there isn't, "Oh, they're doing this or they're doing that," but everybody understands everybody's world.

Mary Nix: Okay. Everyone, thank you. This is Mary Nix again, back at AHRQ. We've come to the end of our web event. It's hard to believe that time just flew by so quickly. I'd like to thank our moderator, Ronie, our presenters, Linda and Janell and of course, you, our audience. We do this for you. We ask that you complete the web event evaluation which will appear shortly. It helps us to improve our offerings. It allows us to know what it is you need and how we can, if we can, best meet your need around innovation and quality.

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