Improving HF public health management and collaborative care

Ryan Haumschild, PharmD, MS, MBA: Let’s talk about accessibility and affordability. It’s great to have amazing treatments for heart failure, but if the patients can’t fill or adhere to these treatments, we won’t see those positive health benefits. How do we discuss public health-management approaches to heart failure but identify opportunities to improve care? I would like to start this first question to Dr. Appal. We have already talked about how we treat these many patients, accumulated or reduced [EF]. But how do we begin to identify and treat patients with heart failure who are at risk for poorer health among themselves? How do we map those risks to identify those who need more timely intervention or intensive treatment to slow progression and provide better outcomes?

Rohit Uppal, MD, MBA, SFH: Great question. The advantage of being a hospitalist is that we have a wealth of information at our fingertips. Many high-risk indicators, especially for morbidity and mortality, are present in the hospital. We always have BNP. [brain natriuretic peptide]. We have the patient’s GFR [glomerular filtration rate]. These patients are on telemetry, so we are identifying ventricular arrhythmias. We know their EF. We know they need enterops. We took our history, so we know their NYHA [New York Heart Association] Room. We know they were intolerant of medical treatment. All of these clues help us stratify high-risk patients based on their clinical characteristics. You have to combine that with the social parameters of health, which also increases the risk of that.

Once you identify high-risk patients, it is a daunting challenge for any clinic, and certainly for hospitalists, to address all of the medical and social issues of this population. We just talked about group care. It takes a village to treat these high-risk patients. One of the ways we train our clinicians is to provide them with the knowledge and skills to conduct effective advanced care planning discussions with these patients. It is important to make advanced care planning a routine part of our care for these patients. That improves quality of life and has an impact on the cost of care.

Emphasizing that team-based approach, you should have an effective multidisciplinary team that includes nurses, case managers, pharmacists, social workers, and nutritionists. Hopefully you have a palliative care team and hospice professionals in your facility or community. Another important part of the team for these patients is the advanced heart failure team or cardiologists. You want to get them involved early on to help manage some of these important decisions.

Ryan Haumschild, PharmD, MS, MBA: Dr. Appal, you talked about team-based care and great team members coming into play. Another thing I think about a lot is the payer. They are part of the team in caring for the patient. They provide support. Dr. Murillo, from your perspective, what are some of the payer-level support programs for patients with heart failure, both for case management and some type of surveillance? Do we have a better chance of working together to get these at-risk patients enrolled in these programs and have better management and control?

Jaime Murillo, MD: I like that question. Thank you for asking me. As I mentioned earlier, the health plans are taking a more active role in helping people stay healthy and making the system work better for everyone. There are many ways. There are pilots across the country from various payers regarding remote patient monitoring and working with ACOs. [accountable care organizations]Health systems and employers need to know how to best care for those patients, how to prevent complications, etc.

You’d be surprised to hear that health plans are eager to collaborate and develop new interventions to help people. Heart failure is a critical area. If there’s an area where there’s an opportunity to collaborate with a health plan, and if there’s a new way of thinking about it, I encourage our audience, especially those in medicine, to go to a health plan and say, “Let’s work together.” It’s not just about negotiating a contract on how to pay. “What can we do together to make our patients better?” Ask. They will be very receptive. Thanks for the question.

Ryan Haumschild, PharmD, MS, MBA: Yes, I like this approach too. It is a cooperative front. Dr. Appal, when we think about public health, when I think about any type of patient, especially heart failure, we need to have some measure of success. We want to know if our intervention was successful. We can monitor and track them over time. As a scientist and physician, you know this. What interventions are you trying to do? What metrics are you tracking to see what impact they have on our patient outcomes?

Rohit Uppal, MD, MBA, SFH: One ongoing challenge is integrating all the data sources we have. In the hospital – we also get some data from the payers – some of the parameters we control are the length of stay of the patients; 3 days, 7 days, 30 days and 90 days return rates; death rate; referral rates to hospice and palliative care; and cardiology referral rates. We also look at our patient experiences as a strong driver of patient adherence after hospital discharge.

Ryan Haumschild, PharmD, MS, MBA: Dr. Anderson, I have a question. Can you discuss some best practices in your organization to guide appropriate care? Do you have treatment options? Do you have specific guidelines, policies, EMRs? [electronic medical records]? How does that guideline-based approach affect heart failure treatment from a payer perspective?

John E. Anderson, MD: That’s a very good question. I’ll get back to it in part 2. In the hospital, we have a large guideline based treatment. What to Expect and Guideline Based Treatment We have expectations from many organizations. When you get to the outpatient setting, some have it, some don’t. For example, I don’t have anything in my EMR system that induces SGLT2 inhibition or ARNI. [angiotensin receptor-neprilysin inhibitor]. We can do better by taking a strategic approach.

Ryan Haumschild, PharmD, MS, MBA: Since you want to create consistency, a systematic approach seems like the right way to go. Dr. Januzzi, what are some of the best practices you’ve seen? Is it order sets in the EMR? What are you looking for to create that consistent practice?

Jim Januzzi, MD: Each institution has a different opportunity. We use medical treatment based on the guidelines [GDMT] Clinical presentation. Embedding in an electronic medical record is an interesting approach that has not been sufficiently explored. A recent PROMPT-HF trial from the Yale University System showed that the rapid approach to EMR improved GDMT. Importantly, it took 10 questions before 1 change was made, so although it seems like an important way to improve care, it needs to be emphasized that more work is needed to better understand how we can encourage clinicians to follow our guidelines. Telling them again. Because you can ask all day, but if you don’t make the changes, it won’t necessarily improve care.

Finally, it comes down to education. The American College of Cardiology’s Expert Consensus Decision Pathway document, which focuses on this approach, comes with a smartphone app that clinicians can use at the bedside or in the office. It is another way to use new techniques and technologies to learn how to use GDMT effectively.

Ryan Haumschild, PharmD, MS, MBA: I love the styles. There are tons of apps out there, but if it’s in the palm of your hand and gives you better performance, it’s not a bad thing to have.

Transcript edited for clarity.