Unite to Thrive: Building an Interdisciplinary Team for Heart Failure Care

Abstract

Background

In 2018 Northwestern Lake Forest Hospital initiated the hospital's first Heart Failure program. At that time, it was a suburban hospital with 114 licensed beds. The program was developed in response to enrollment with the Medicare Bundled Payment initiative and high readmission rates within the heart failure patient population. At that time the readmission rate was over 18% for 30-day all-cause readmissions and the hospital saw 292 patients with a primary diagnosis of heart failure.

Purpose

We recognized the need to develop a structured interdisciplinary Heart Failure team that would be able to improve access to clinical care and provide interventions to reduce readmission rates for multiple different angles. In turn the goal was to improve patient outcomes and satisfaction.

Setting/Population

The team cared for patients in the acute hospital setting as well as in the ambulatory clinic post discharge. We focused interventions on patients admitted with a heart failure exacerbation.

Method/Process

Developed an interdisciplinary team that consists of RNs (ambulatory clinic, navigators, Clinical Documentation Specialist), APRNs, MDs, PharmD, Pharmacy Technician. The inpatient Heart Failure team consists of a Heart Failure MD, APP, PharmD, and navigator; this team evaluates all patients with a primary heart failure diagnosis provided both medical care and self-management education. The interdisciplinary team meets weekly to review heart failure readmissions, currently admitted patients, patients within the 30-day window of discharge, and all CardioMEMs patients. A heart failure Epic InBasket Pool was created to allow for streamlined communication between with entire team.

Outpatient interventions implemented to assist in reducing readmissions were discharge callbacks within 72 hours, APP run heart failure clinic with hospital follow up appointments as well as urgent appointment slots for new or worsening symptoms, ability to administer IV push diuretics in the outpatient setting, PharmD run Medication Adjustment and Titration (MAT) clinic, Pharmacy Technician assistance with medication access and affordability, free transportation to assist patient is coming to the scheduled appointments, and development of CardioMEMs program.

Outcome Measures

Since the inception of the interdisciplinary Heart Failure team, the program saw an 82.5% growth in patient volumes while working to decrease the readmission rate by 27.7%. Furthermore, patients with CardioMEMs reduced their number of heart failure hospitalizations by 82% post implant and the patients that utilized the IV diuretic infusion clinic had a 30 day all cause readmission rate of 6.8%. While introducing a PharmD MAT Clinic allowed for fewer APP visits for GDMT titration, which in turn increased access on the APP clinic schedules for other types of patient appointments. In the first year the MAT clinic enrolled 93 patients, increasing the number of patients who were on all four pillars of GDMT from 43% before the MAT to 76% after enrollment. 49 MAT clinic patients also had improvements in ejection fraction.

Practical Implications

By utilizing an interdisciplinary team, our Heart Failure Program has been able to see improved workflows and patient outcomes even with continued growth in number of patients. The team has developed a sense of teamwork and accountability towards each other translating to better clinician satisfaction.