Kaleida Health

Get With the Guidelines

Michael Campo MHSA.

Quality Director, CV Services

Natalie Kaufman, RN

Manager Cardiac Rehabilitation

Kaleida Health

Program Overview

Heart Failure

• 5 million Americans have the disease

• More than 500,000 are newly diagnosed each year

• HF results in 2 million hospitalizations annually and accounts for 3% of the national health care budget ($27.9B)

• HF is the most commonly used Medicare diagnostic related group (DRG)

• 6.5 million hospital days

• High readmission rate 20% @ 30 days, & 50% @

6 months

• 12-15 million office visits annually

• Approximately 300,000 death annually are related to HF

Costs for HF in the US (in $ billions)

Indirect

Costs, $2.1

Nursing

Home, $3.5

Provider,

$1.8

Drugs, $2.1

Home

Health, $2.1

Hospital,

$13.6

Re-admission/Disease Progression

Practitioner

Failures

Failure to prescribe

evidence-based medications

Failure to discontinue

medication that may

exacerbate HF

Failure to adjust

medications

Failure to adequately

address co-morbidities

Failure of adequate

follow-up

System

Failures

Failure to provide

adequate dietary

counseling

Failure of adequate

discharge planning

Failure to address

patient and caregiver

needs

Failure to adhere

to prescribed medications

Failure to comply with

dietary regimen

Failure to seek early

care with escalating

symptoms

Failure of patient

social support systems

Patient

Failures

EVIDENCE-BASED MEDICINE

AHA/ACC Guidelines

• The GWTG-HF performance measures

are based upon the evidenced-based

ACC/AHA HF Guidelines

• GWTG is about improved communication

and developing better systems and

processes. It is essential to include all

staff positions both directly and indirectly

involved in these patient care.

ACC/AHA Practice Guidelines

Class IA

Benefit >>> Risk

Procedure or

treatment SHOULD

be performed or

administered

Class IIa

Benefit >> Risk

Additional studies

with focused

objectives needed

IT IS REASONABLE

to perform procedure

or administer

treatment

Class IIb

Benefit ≥ Risk

Additional studies

with broad objectives

needed; Additional

registry data would

be helpful

Procedure or

treatment

MAY BE

CONSIDERED

Class III

Risk ≥ Benefit

No additional studies

needed

Procedure or

treatment should NOT

be performed or

administered SINCE IT

IS NOT HELPFUL

AND MAY BE

HARMFUL

Applying Classification of

Recommendations and Level of Evidence

CMS/HQA/GWTG-HF Core Measures

• Class Ia recommendations

• Measure LV Function

• ACEI/ARB at Discharge

• Smoking Cessation

• Beta Blocker Usage at Discharge

• Discharge Instructions

QUALITYPROCESS

IMPROVEMENT

Quality ImprovementProcess-Disease

Implement

Quality

Improvement

Initiative

Data Collection

Data

Review

Process

Identify Intervention

Targets

FOCUS-PDCA

• F-ind a process to improve– High Cost, High Volume, High Variation

• O-rganize a team that knows the process

• C-learify the current knowledge of the process

• U-nderstand the causes of process variation

• S-elect the process improvement

Plan Do Check Act

Modification to

process

Tracking

Outcomes

Provider Feedback

Concurrent Review Identification

of Patient

Population

Site Specific Team

Physician

Involvement

Staffing

Organization &

Structure

Planning

& Startup

GWTG-HF

Quality Management Plan Review Checklist

• - Quality improvement infrastructure

• - Quality plan implementation

• - Performance measurement

• - Participation of stakeholders

• - Evaluation

• - Capacity building

• - Process to update the plan

• - Annual quality goals Pay for Performance

• - Communication

Site Specific Team

• Administrators

• Physicians

• Nurses

• Cardiology

Unit Nurse Managers

• QI Staff

• Pharmacists

• Discharge Planners

• Patient Education

• Case Managers

• Nurse Practitioners

• Cardiac Rehab Staff

GWTG-HF Process

Cardiac Rehab. Dept. MFS

GWTG-HF Coordinator

BNP Report

Lasix Report

Daily

Cardiac Rehab

Orders

Daily

Census

Reports

Dx, SOB,

edema, etc.

Daily

QDC list for

cardiac rehab

Daily f/u with pt checking for

Guideline Compliance

Cardiac Rehab performs pt

education

f/u with MD

By

Coordinator

Corrective

action taken

Dr. Matthews

contacted if necessary

Reports

generateed

by site, unit

and MD

Discharge

Planners if pt

not seen prior

to discharge

Reports distributed on monthly

basis

GWTG-HF Process

MFS

Information

entered into

MD tracking

tool

Data is entered

into Patient

Management

Tool

QUALITY MEASURES – KEY POINTS PLU sticker

Date______________ Room/Site _____________

EF% Date EF done

or date ordered ____________

Yes No

EF <35% referred for consult with EP □ □

MD Questionnaire In chart □ □

Discharge instructions given: □ □

Document all 6 instructions in the Cardiac Management

Discharge Record (Activity, Diet, Medications, Weight

Monitoring, Follow-up appt, Action if symptoms worsen

Quality Measures Key Points

□ An MI (elevated trop or CK with PCI or CABG)

If so, is there a discharge order for:

Yes NoASA □ □Beta Blocker □ □ACE/ARB for EF <40% □ □Smoking Cessation □ □Cardiac Rehab □ □

For all “no” answers, contact primary MD if a specific reason is not documented.

Quality Measures Key Points

□ Hx CHF

□ CHF, elevated BNP, pulmonary edema, biventricular device placed.

If so, is there a discharge order for: Yes No

ACE/ARB EF<40% □ □

(no letter needed)Beta blocker □ □Has an EF% been assessed/documented?(echo) □ □

NYS Class for Heart Failure documented □ □

NYS Class

For all “no” answers, contact primary MD if a specific reason is not documented

____________

Initials

Date

Quality Measures Key Points

Cardiac Management Tool

IA. Discharge Order

Discharge Diagnosis:

Allergies:

MEDICATIONS: Medication to be taken after discharge *Rx -

Prescription

A. CARDIAC MEDICATIONS

Aspirin:______________mg by mouth

Clopidogrel (Plavix) 75 mg by mouth

ACE Inhibitor: _____ mg by mouth

ARB: _____________ mg by mouth

Beta Blocker: _______ mg by mouth

Statin:______________ mg by mouth

Cardiac Management Discharge Record

• Discharge Order

– Cardiac Medications

– Previous Medications

– New Medications

• Discharge Instructions

QUALITY

OUTCOMES

Left Ventricular Assessment

75%84%

92%100%100%97%100%

0%

25%

50%

75%

100%

Jan March May July

ACEI/ARB for LVD

78%

100%91%

80%85%

92%85%

0%

25%

50%

75%

100%

Jan Feb March April May June July

Smoking Cessation

100%100%100%100%100%100%100%

0%

25%

50%

75%

100%

Jan Feb March April May June July

Beta Blocker at Discharge

89%80%

100% 94% 89%92% 88%

0%

25%

50%

75%

100%

Jan Feb March April May June July

Patient Instructions

•Monitor daily weights

•Salt restricted diet (e.g. 2 gm sodium diet)

•Medications, need for adherence

•Activity Rx

•Smoking Cessation Advice/Counseling

•What to do if HF symptoms worsen

•Close follow-up and monitoring

Discharge Instructions

82% 85% 83%88%

100%100% 96%

0%

25%

50%

75%

100%

Jan Feb March April May June July

HF Composite Score

HF Defect Free Score

Score

Length of Stay

6.34.89

7.3

6.1

012345678

Sept Oct Nov Dec

mean = 6.14

LOS w the Deletion of LOS > 2 Stdev

Sept-Dec 07

Length of Stay

5.2 5.4 5.85.3 5.3 5.2 4.9

1

2

3

4

5

6

7

8

Jan March May July

mean = 5.2

LOS w the Deletion of LOS > 2 Stdev

Jan - July 2008

Cost Impact Of Heart Failure

DRG 127

Mean

reimbursement

$4,617

Mean Cost 5,905 ($1,293)

Break even point

(R=C)

5.0 days

Cost/hr. $49.20

* Short Stay Management

of HF (2006). Peacock, F

Cost Savings

LOS Hrs. Rate Cost Pts

Sept-

Dec

6.14 147.36 $49.20 $7,250 184 $1,334,020

April-

July

5.2 124.8 $49.20 $6,140 184 $1,129,789

$204,231

Summary

• All patients with chronic HF deserve

guideline based medical therapy

• With fewer “new” therapies - systems of

care delivery increasingly important

WHERE WE

ARE HEADEDCardiac Center of Excellence

Accomplishments

Short-Term Goals

Long-Term Goals

Overarching Goal

Where Are We Going

• Accomplishments-– Accredited Chest Pain Center Buffalo General Hospital July

2007

– Millard Fillmore Suburban Hospital-AHA Bronze Award Winner August 2008

• Short Terms Goals-– Embed GWTG-HF Culture at Buffalo General Hospital

– Roll-out GWTG-HF at Millard Fillmore Gates Hospital

– Chest Pain Center Accreditation Millard Fillmore Suburban

• Long Terms Goals-– Continue to improve the established processes

– Investigate the possibility of incorporating GWTG- Coronary Artery Disease

Where Are We Going

• Overarching Goal-

– To establish Kaleida Health as a Center of Excellence

for Cardiovascular Health, through

the establishment of:

- Global Vascular Institute 2011

– Accredited Chest Pain Centers

– Surgical/Procedural Centers of Excellence

– Cardiac Specialty Clinics

» Syncope

» Atrial Fibrillation

» Devices

» Heart Failure

CARDIAC CENTER OF

EXCELLENCE

To develop a full-service, regional

referral center within a “hybrid model” of

practicing and academic cardiologists,

working in unison with UB, whose clinical

and QI outcomes are benchmarked to

the top 10% of all cardiovascular

programs nationally.

Overarching Goal