The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: heart failure (page 1 of 5)

Michigan Hospital on the Forefront of Reducing Hospital Readmissions

Dino Recchia

Dr. Recchia is Chief of Cardiology at Munson Medical Center

Some goals of the MVC Hospital Engagement team are to help hospitals reduce Heart Failure (HF) readmission rates along with improving patient care and quality in order to have Michigan become a leader in this domain. The Hospital Engagement team has been locating and speaking to hospitals nationwide with the lowest HF-related readmissions. One hospital, Munson Medical Center, falls in the top 1% of hospital readmissions and is located right in Michigan. Munson is on the forefront of using coordination of care to reduce readmissions. The Hospital Engagement team had the opportunity to speak to Dr. Recchia, Sheila Falk, and Anne Bacon about the HF Clinic at Munson Medical Center, which has helped better manage patients and improve readmission outcomes among their sickest patients.

The clinic was the shared vision of Dr. Recchia and Sheila Falk who began planning the program in 2010.  They identified gaps in the care of many heart failure patients which was resulting in high rates of readmissions and sub-optimal quality of life.  They also saw the growing role of LVADs in the management of end stage heart failure which presented difficulties for LVAD patients in northern Michigan who lived many hours away from an LVAD center.  A similar situation existed for patients with pulmonary hypertension.  They approached the Munson Foundation with a plan to establish a multidisciplinary heart failure program to address the needs of this difficult patient population. With seed monies from the Foundation, the Munson Heart Failure Clinic was established in 2011.

Patient Management

The clinic has grown dramatically over the last 5 years now involving a heart failure cardiologist, special heart failure nurse practitioner, 3 dedicated nurses, and 2 support staff.  90% of the referrals to the program come from Dr. Recchia’s partners and involve cases that are too complex to manage in a general cardiology practice.   Once the patient is referred, care is taken over completely by the Heart Failure clinic with no co-managing between cardiologists. Patients referred to the HF Clinic begin care management the day they are discharged. Inpatients are seen and educated by the nurse prior to discharge as the team found that the time between discharge and their first HF Clinic appointment is a very vulnerable time.  The Munson team has also developed a “shared care” approach for patients with LVADs allowing these patients to be co-managed with their implanting LVAD centers downstate greatly reducing the frequency with which patients and their families have to drive long distances for a routine LVAD follow up appointment.  The same approach is used for co-managing patients with pulmonary hypertension seen in those same institutions.  Another unique feature of the HF Clinic at Munson Medical Center is the phone call strategy they employ.  Instead of suggesting patients call the HF Clinic if something is wrong after a change in their treatment regimen is made, the HF Clinic team arranges a “phone call appointment” at a specific date and time to follow-up on the response to the treatment and facilitating further decision making. These patient management methods at the Munson Medical Center HF Clinic help better coordinate care and consequently improves patient experience and outcomes. Patients reap such benefits from being in the program that they often want to stay in the program even after they have improved enough to no longer need this level of care.  Munson has also had great success integrating hospice care in to their program for those patients that have no further care options resulting in over 60% of the deaths in the program occurring in a hospice setting.

Outcomes and Measurement of Success

Readmission rates can be used as a measurement of success of a program geared towards improving patient care and costs. Munson took less than 2 years to measure the positive outcomes the clinic had on patient care and on readmission rates. Munson’s overall hospital readmission rate for heart failure is 18.6% down from 23% before the HF program was established.  The national average for this metric is 22%.  The patients followed by the HF Clinic are the most difficult heart failure cases with a predicted readmission rate based on clinical parameters of over 25% yet this subgroup had an overall readmission rate of only 12% which is a further testament to the success of the program.  Moreover, Munson has used patient testimonials and resource usage to measure the downstream impact of the HF Clinic and shown benefactors the benefit of investing in a HF clinic.

Advice to Hospitals

Munson was able to provide great advice for hospitals seeking to begin a HF Clinic program. First and foremost, there has to be complete buy-in from the cardiologists where the specialty clinic takes over care for the patient so there is no confusion. Hospitals should structure a multi-disciplinary clinic where each member works to the full potential of their credentials. This ensures coordination of care among services and makes patients feel secure in their decision to use the HF Clinic services. This team is critical to ensuring that patients are receiving timely and quality care.

Dr. Recchia and the HF Clinic team are happy to talk to anyone interested in finding out more about the clinic at Munson. Please contact Deb Evans (debevans@med.umich.edu), Abeer Yassine (abeery@med.umich.edu), or Dr. Recchia (drecchia@mhc.net) for more information.

Hospitals in Michigan: Growing a Palliative Care Program

Melinda Gruber

Melinda Gruber MBA, PhD, is the Chief Executive Officer for Caring Circles.

Palliative care provides a number of benefits for patients of all diagnoses including Congestive Heart Failure (CHF). During the CHF workgroups a topic for discussion was how palliative care programs can reduce readmissions and the MVC Hospital Engagement team found out more about some palliative care programs here in Michigan.

BACKGROUND

Lakeland Hospital started their palliative care program in the outpatient sector through a local independent hospice after recognizing that patients would benefit from improved symptom and pain management along with advanced care planning. By 2008, Lakeland realized they needed to engage a physician champion who was both well-known and accepted throughout the community with a vision for both inpatient and outpatient palliative care. In 2012, the outpatient hospice program joined Lakeland and a business plan was proposed to add an inpatient program. This program has grown and received positive feedback, and Lakeland now has a Hospice and Palliative Medicine Fellowship. Recently they have worked with home care and have started to provide a palliative home care service that is actively growing. As the program evolves, Lakeland continuously assesses the needs of the program to determine where to best allocate resources.

BENEFITS

The benefits of the palliative care program at Lakeland include an added layer of support for both patients and their families. Additionally, examples show reduced readmissions, better pain and symptom management, increased support for the family, and patients meeting their goals in end of life care surrounded by family who have been prepared.

While partnering with other outpatient and inpatient palliative care programs throughout the area, Lakeland is learning the strengths of each to provide for the varying needs of the patients.

CHALLENGES

One of the challenges Lakeland faces is an ongoing lack of understanding about palliative care and its true value to the patient. There is also the challenge to convince the provider that the palliative care team is there to assist with the patient’s needs and not completely take over care of the patient. To address these challenges, the palliative care program at Lakeland takes on the responsibility of educating and coaching staff to provide them with a minimum foundational skill to deliver palliative care and explain how and why the palliative care approach was taken. This helps those involved in patient care understand the different approaches to care given, and how the palliative care program works.

Other challenges being faced by Lakeland are identifying what the optimal approach for palliative care is, staffing needed to provide palliative care and setting expectations to deliver consistent care.

LIAISONS

Lakeland partners with Agency on Aging which includes an interdisciplinary team that goes to a patient’s home and provides dietary and medication advice. Lakeland’s palliative care program also has relationships with primary care for the homebound, nursing homes, hospitalists, hospices, intensivists, and consultation programs for all-inclusive care.

EDUCATION

Lakeland stresses the importance of palliative care education and provides opportunities for growth in learning such as:

  • Huddles with the hospitalists and working more with the residents;
  • Lunch and learns for CME credits; and
  • A patient care summit on the benefits of palliative care

NEXT STEPS

As the palliative care program at Lakeland continues to grow, the palliative care team perform needs assessments to ensure the program is meeting the needs of the patient and the health system. They also utilize data in a simplistic understandable way to demonstrate the value of the program to high level leadership. Moving forward, they have scheduled to attend meetings at provider offices to build relationships and provide educational opportunities to clinicians.

ADVICE

Lakeland advises other hospitals to recognize that there is not one set way to provide palliative care. They recommend setting expectations up front, developing objectives to meet the needs of both the patient and the health system, and finding “champions” and get them engaged in palliative care initiatives.

Lakeland is also seeking advice for how clinicians can be consulted ahead of a patient “crisis”. Team members are currently on call 24/7 but they would like to find ways that the team can be more consistent with providing consults especially in the off shifts.

If you would like to learn more about the palliative care program at Lakeland Hospital, please contact Doris Glowacki at dglowacki@Caring-Circles.org or the MVC Coordinating Center.

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