Improving the health management of the heart failure population and collaborative care

Ryan Haumschild, PharmD, MS, MBA: Let’s talk about access and accessibility. It’s great to have wonderful therapies for heart failure, but if patients aren’t able to fill them or don’t adhere to those therapies, we won’t see these positive health benefits. How do we discuss population health management approaches in heart failure, but also identify opportunity to improve care? I want to start this first question for Dr. Uppal. We talked earlier about how we’re going to treat many of these patients the same way whether they have preserved or reduced ejection fraction [EF]. But how do we begin to identify and treat heart failure patients who are at risk for poor health outcomes among themselves? How do we stratify these risks to identify those who need more timely intervention or intensive therapy earlier to slow progression and provide them with better outcomes?

Rohit Uppal, MD, MBA, SFH: Great question. The benefit of being hospitals is that we have a lot of data. Many of the high-risk indicators, particularly for morbidity and mortality, are available in the hospital setting. We always have GNP [brain natriuretic peptide]. We have the patient’s GFR [glomerular filtration rate]. These patients are on telemetry, so we identify ventricular arrhythmias. We know their EF. We know if they needed inotropes. We got our history so we know their NYHA [New York Heart Association] class. We know if they have been intolerant to medical therapy. All of these clues help us separate high-risk patients based on their medical characteristics. You have to combine this with the social determinants of health that also add to this risk.

Once you identify high-risk patients, it is a daunting challenge for any clinician, and certainly for hospitals, to address all of the medical and social issues of this population. We just talked about taking care of the team. It takes a village to treat these high-risk patients. One of the ways we train our clinicians is to give them the knowledge and skills to have effective care planning conversations with these patients. Making advanced care planning a standard component of our care for these patients is essential. This improves their quality of life and affects the cost of care.

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

Ryan Haumschild, PharmD, MS, MBA: Dr. Uppal, you talked about team care and so many great team members springing into action. Another one I think about a lot is the payer. They are part of the patient care team. They provide support. Dr. Murillo, from your perspective, what are some of the support programs at the payer level for heart failure patients, whether for case management or some kind of navigator? Is there a better opportunity to work more closely together for these at-risk patients to get them into these programs and have better management and oversight?

Jaime Murillo, MD: I love this question. Thank you for asking this. As I mentioned earlier, health plans are taking a more active role in helping people be healthier and helping the system work better for everyone. There are many ways. There are pilot projects across the country from various payers to remotely monitor patients and work with ACOs [accountable care organizations]health systems and employers on how to better care for these patients, how to better prevent them from complications, etc.

You’d be surprised to hear that health plans are willing to collaborate and establish innovative 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 there’s innovative thinking about it, I would encourage our viewers—especially those who practice medicine—to go to the health plans and say, “Let’s work together.” It’s not about only to negotiate a contract regarding the method of payment. Ask, “What can we do together to make our patients better?” They will be very receptive. Thank you for this question.

Ryan Haumschild, PharmD, MS, MBA: Yeah, I love that approach too. It is a cooperation front. Dr. Uppal, when we think about population health, when we think about any type of patient, particularly with heart failure, we need to have some measures of success. We want to know that our interventions are successful. We are able to monitor and track them over time. As a scientist and doctor you are familiar with this. What interventions are you trying to do? What metrics do you monitor to see what type of impact they have on outcomes for our patients?

Rohit Uppal, MD, MBA, SFH: One challenge we have across the continuum is integrating all the data sources we have. Within the hospital space—we also get some data from payers—some of the metrics we look at are inpatient length of stay; readmission rates at 3 days, 7 days, 30 days, and 90 days; death rates; referral rates to hospice and palliative care; and referral rates to a cardiologist. We also look at our patient experience outcomes, which are a strong driver of patient retention once they leave the hospital.

Ryan Haumschild, PharmD, MS, MBA: Dr. Anderson, I have a question for you. Can you discuss some of the best practices in your organization for targeting appropriate care? Do you have treatment paths? Do you have specific guidelines, policies, EMRs [electronic medical records]? How might this guideline-based pathway impact heart failure treatment and from a payer perspective?

John E. Anderson, MD: That’s a great question. I will answer in 2 parts. We have great guideline-based therapy at the hospital. We have expectations from a number of organizations about what is expected and what guideline-based therapy is. When you get to outpatient settings, some have it and some don’t. For example, I have nothing built into my EMR system to suggest SGLT2 inhibition or ARNI [angiotensin receptor-neprilysin inhibitor]. We can do a better job with a systematic approach.

Ryan Haumschild, PharmD, MS, MBA: It sounds like a systematic approach is probably the way to go because you want to create consistency. Dr. Iannuzzi, what are some of the best practices you’ve seen? Is an order placed in the EMR? What do you see to create this consistent practice?

Jim Iannuzzi, MD: Each institution has different options. We use management-directed medical therapy [GDMT] clinical approach. Embedding in the electronic medical record is an interesting approach that has not been sufficiently explored. The recent PROMPT-HF trial from the Yale University System showed that the EMR-rapid approach improves GDMT. Importantly, it took 10 prompts before 1 change was made, so it needs to be emphasized that although this appears to be a potentially useful way to improve care, more work needs to be done to better understand well how to encourage clinicians to follow the prompts we tell them. Because you can suggest all day, but if they don’t make the changes, it’s not necessarily going to improve care.

In the end, it all comes down to education. The American College of Cardiology Expert Decision Pathway document, which focuses on this approach, also comes with a smartphone app that clinicians can use at the bedside or in the office. This is another way to use newer techniques and technologies to learn how to use GDMT effectively.

Ryan Haumschild, PharmD, MS, MBA: I like the strategies. It has many uses, but if it’s at your fingertips and provides better practice, it’s not a bad thing to have.

Transcript edited for clarity.

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