Improve SE population health management and collaborative care
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: Let’s talk about access and affordability. It’s great to have wonderful therapies for heart failure, but if patients aren’t able to fulfill them or if they don’t stick with those therapies, we’re not going to see those positive benefits for health. How do we discuss population health management approaches for heart failure, but also identify an opportunity for us to improve care? I want to start this first question to Dr. Uppal. We talked earlier about how we’re going to treat many of these patients the same whether they have preserved or reduced ejection fraction. [EF]. But how can we begin to identify and treat heart failure patients who are at risk of poor health outcomes among themselves? How do you stratify these risks to identify those who need faster intervention or intensive therapy sooner to slow progression and give them better outcomes?
Rohit Uppal, MD, MBA, SFH: Excellent question. The advantage of being a hospitalist is that we have a lot of data at our disposal. Many indicators of high risk, including morbidity and mortality, are available in the hospital setting. We still have a BNP [brain natriuretic peptide]. We have the GFR of the patient [glomerular filtration rate]. These patients are on telemetry, so we identify ventricular arrhythmias. We know their EF. We know if they needed inotropes. We took our story, so we know them NYHA [New York Heart Association] to classify. We know if they have been intolerant to medical therapy. All of these indices help us to stratify high-risk patients according to their medical characteristics. You have to combine that with the social determinants of health, which also add to that risk.
Once you have identified high-risk patients, it is a daunting challenge for any clinician, and certainly for hospitalists, to address all of the medical and social issues in this population. We just talked about team care. It takes a whole village to care for these very high-risk patients. One of the ways we train our clinicians is to give them the knowledge and skills to have effective conversations about advanced care planning with these patients. It is essential to make advanced care planning a standard component of our care for these patients. This improves their quality of life and has an impact on the cost of care.
Emphasizing this team approach, you need to have an effective multidisciplinary team that includes nurses, case managers, pharmacists, social workers, and nutritionists. I hope you have a palliative care team and palliative care practitioners in 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 involve them early on to help manage some of those important decisions.
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: Dr Uppal, you talked about team care and so many great team members that come into play. Another one I think about a lot is the payer. They are part of the team in terms of patient care. They provide support. Dr. Murillo, from your perspective, what are some of the payer-level support programs for heart failure patients, whether it’s case management or some type of navigator? Is there a better opportunity for us to work more closely together for these at-risk patients to enroll them in these programs and to have better management and oversight?
Jaime Murillo, MD: I love this question. Thank you for asking this question. 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 pilots across the country from different payers on remote patient monitoring and working with ACOs [accountable care organizations]health systems and employers on how to better care for these patients, better prevent them from having complications, etc.
You’d be surprised to learn that health plans are eager to collaborate and establish innovative interventions to help people. Heart failure is a critical area. If there is an area where it is possible to collaborate with a health plan, and there is innovative thinking about it, I would encourage our viewers, especially those who practice medicine, to go to health plans and to say, “Let’s work together”. It’s not just about negotiating a contract about how to pay. Ask: “What can we do together to improve the health of our patients?” They will be very receptive. Thank you for this question.
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: Yes, I also like this approach. It is a collaborative front. Dr. Uppal, when we think of population health, when I think of any type of patient, especially heart failure, we have to have measures of success. We want to know that our interventions have been successful. We are able to monitor and track them over time. As a scientist and a physician, you are aware of this. What interventions are you trying to do? What metrics do you monitor to see what kind of impact they have on our patient outcomes?
Rohit Uppal, MD, MBA, SFH: One of the challenges we face along the continuum is integrating all the data sources we have. In the hospital space – we also get data from payers – some of the metrics we monitor are length of hospital stay; readmission rates at 3 days, 7 days, 30 days and 90 days; mortality rates; palliative and palliative care referral rates; and cardiology reference rates. We also look at our patient experience scores, which are a powerful driver of patient adherence once they leave the hospital.
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: Dr. Anderson, I have a question for you. Can you discuss some of your organization’s best practices to guide appropriate care? Do you have care pathways? Do you have specific guidelines, policies, EMRs [electronic medical records]? How can this guideline-based pathway also influence heart failure treatment from a payer’s perspective?
John E. Anderson, MD: That’s an excellent question. I will answer it in 2 parts. At the hospital, we have excellent therapy based on guidelines. We have expectations from a number of organizations about what is expected and what guideline therapy is. When you come in as an outpatient, some have it and some don’t. For example, I have nothing built into my EMR system that causes SGLT2 inhibition or ARNI [angiotensin receptor-neprilysin inhibitor]. We could do a better job by taking a systematic approach.
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: It seems like the systematic approach is probably the right way to go because you want to create consistency. Dr. Januzzi, what are some of the best practices you’ve seen? Are these order sets in the DME? What do you see to create this consistent practice?
Jim Januzzi, MD: Each institution has a different opportunity. We use guideline-directed medical therapy [GDMT] clinical approach. Integration into the electronic medical record is an interesting approach that has not been sufficiently explored. The recent PROMPT-HF trial of the Yale University system showed that a prompting approach to DME improved GDMT. It’s important to note that it took 10 prompts before a change was made, so it’s worth pointing out that while this sounds like a potentially useful way to improve care, there’s still work to be done. to better understand how to encourage clinicians to follow the prompts we’re telling them. Because you can ask all day, but if they don’t make the changes, it won’t necessarily improve the care.
Ultimately, it comes down to education. The American College of Cardiology Expert Consensus Decision Path that 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 take advantage of new techniques and technologies to learn how to use GDMT effectively.
Ryan Haumschild, Doctor of Pharmacy, MS, MBA: I like strategies. There are plenty of apps out there, but if they’re at your fingertips and offer best practice, that’s not a bad thing to have.
Transcript edited for clarity.