CLARION Interprofessional Case Competition “The Heart of the Matter”

1. CLARION Interprofessional Case Competition “The Heart of the Matter”

2. Our Team

3. The Heart of the Matter:Chronic Heart Failure (CHF) 5.1 million Our Purpose To recognize and eliminate the gaps and failure points that prevent optimal heart failure care at WestPlan

4. Chronic Heart Failure & WestPlan • 1,817 WestPlan members have CHF • 184 (10.2%) members participate in our Disease and Case Management Program

5. Insured by Medicare Retired Mechanic 69 Years Old Family History Margie Reeves Harlan Reeves Smoking & Drinking Robert & Lisa Reeves Stressors Sedentary Lifestyle & Poor Diet

8. MI at home/placement of stent/pacemaker at Central Hospital (7months ago) Hospitalization for deteriorating condition and admitted as an inpatient to the transitional care unit (2 weeks ago) Development/dx of DM II (12 years ago) Poor handling of CHF dx 14 mos. ago Admitted only for observation 3 weeks ago …no Transitional Care High BMI due to poor lifestyle Non-adherence to cardiac medication regimen Poor coordination of care for DM II and CHF Margie and Lisa now physically unable to care for Harlan Family History of DM II The system failed Harlan Reeves Fragmented health records Rejected palliative care 7 months ago Low health literacy Unmanaged DM II Continued smoking and sedentary lifestyle No regular medical checkups Never referred to Heart Clinic or transferred to Transitional Care FH of heart disease Smoking/drinking to deal with stressors Inadequate home care Age/gender: 69 y/o M Diabetic and Cardiac Events in the 7 months following MI/Rushed to the ER (3 weeks ago) Unhealthy Lifestyle Development/dx of Grade III CHF (14 months ago)

9. Harlan’s Health Care

10. Our Recommendations 1. Achieve Advanced Certification in Heart Failure by The Joint Commission 2. Partner with the Dunnelly community to implement population health management Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement

11. Recommendation 1Advanced Certification in Heart Failure

12. Recommendation Strategy [ ] Joint Commission Core Measures in Heart Failure [ ] Joint Commission requirements for Advanced Certification in Heart Failure: INPATIENT and OUTPATIENT [ ] WestPlan considerations for Standards of Care

13. Pathway to Advanced Certification for CHF

14. Tactic 1 : Information Technology • Existing EHR Clinical Decision Support Tool • Cardiac Care Checklist • CHF Risk Assessment Checklist • Oregon’s Health Information Exchange program (Care Accord) • Integrating health records from WestPlan and outside of WestPlan networks

15. Tactic 2: Transition Coordinators • Transform discharge planners into Transition Coordinators • Ensures smooth transition from hospital to next care setting • Follow-up by post-discharge day 7 & connect with Home Care and Hospice services • Goals to achieve: • 80% patient follow-up with PCP, cardiologist, or Heart Failure Clinic or other WestPlan Service • 100% of medications prescribed are filled at discharge with medication instructions understood by the patient • Reduce CHF readmissions by 15% within year 1

16. Tactic 3: Medication Management • Medication Reconciliation • Obtaining medication histories • Reconciling patient’s home medications with updated medication action plans • Interdisciplinary effort • Improving medication safety across the continuum of care • Inpatient stays • Outpatient appointments • Updated personal patient medication lists

17. Tactic 3: Medication Management • Medication Regimen Dose Optimization • Adding a clinical pharmacist to the WestPlan Heart Failure Clinic to help optimize heart failure regimens in the most critical and complex patients • Medication Therapy Management (MTM) • Adding an MTM pharmacist to the Disease and Case Management Program to help improve medication safety for patients not regularly seen in the WestPlan Heart Failure Clinic

18. P4: Home Care and Hospice • Why is Home Care and Hospice important for CHF patients? • Quality of Life • Patient Safety • Reducing hospital re-admissions! • WestPlan’s Home Care and Hospice services are underutilized. Why? • Stigma • Access • Our current team: • Geriatricians, Nurse Practitioners, Nurses, Social Workers, Assisted Living • specialists (home aides), Chaplains • Which roles do we want to add or enhance? • Transition Coordinators • Dietician • Clinical pharmacist

19. P4: Home Care and Hospice How will our improved interdisciplinary team help CHF patients?

20. Recommendation 2Population Health Management

21. Population Health Management • Intensive Case & Disease Management • Chronic disease self-management • Increased enrollment through electronic medical records (EMR) • Health Coaching & Lifestyle Management • Coaching lifestyle choices • Programs for modifying risk factors InformationTechnology • Health Education & Promotion • Raising health awareness • Health promotion programs • Community Partnerships • Incentives • Screening & Annual Visits • Outreach & Awareness Health Risk Assessment OUR COMMUNITY

22. Risk Stratification CHF RISK STRATIFICATION

23. WestPlan Community Care-a-Van • Interdisciplinary Team (Allocated Part Time) • 1 Public Health Specialist (Epidemiologist) • 2 Registered Nurses • 1 Social Worker • Services provided • Blood Pressure and Blood Glucose Readings • BMI Assessments • Tobacco and Alcohol Use Assessments (ASSIST) • Individual Health Risk Assessments • Referrals to WestPlan providers • Care-a-Van operations would partner with the Million Hearts Campaign

24. Raising Health Awareness • WestPlan Community Care-a-Van • “Honoring Choices” • Onsite patient counseling • Health Education and Promotion • Classes on various health topics • Specialized for inpatients, outpatients, or the general public • Community Partnerships • Health Fairs • Engagement with community stakeholders

25. Recommendations 1. Achieve Advanced Certification in Heart Failure by The Joint Commission 2. Partner with the Dunnelly community to implement population health management Images retrieved from: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx Institute of Healthcare Improvement

26. Tactic 1-4 Expenses

27. Tactic 1-4 Cost Savings

28. Care-a-Van Pro Forma Analysis

29. Care-a-Van Pro Forma Analysis

30. Hospitalization for deteriorating condition and admitted as an inpatient to the transitional care unit (2 weeks ago) Harlan Reeves MI at home/placement of stent/pacemaker at Central Hospital Development/dx of DM II (12 years ago) Poor handling of CHF dx 14 mos. ago Admitted only for observation 3 weeks ago …no Transitional Care • Community Care Partners • Health Promotion & Education High BMI due to poor lifestyle • Disease & Case Management • Home Care & Hospice Non-adherence to cardiac medication regimen Margie and Lisa now physically unable to care for Harlan Poor coordination of care for DM II and CHF FH of DM II The system failed Harlan Reeves Rejected palliative care 7 months ago Lack of education Unmanaged DM II • Health Coaching & Lifestyle Management Continued smoking and sedentary lifestyle No regular medical checkups Never referred to Heart Clinic or transferred to Transitional Care FH of heart disease Smoking/drinking to deal with stressors Margie suffering from caregiver’s burden Age/gender: 69 y/o M Diabetic and Cardiac Events in the 7 months following MI/Rushed to the ER (3 weeks ago) Poor lifestyle management Development/dx of Grade III CHF (14 months ago)

31. Thank You