kaleida health get with the...
TRANSCRIPT
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