Daniel J. David, MD, Medical Director, Health Alliance PHO
Matt Cary, MD
Rachel Monderer, MD
Max Bayard, MD
Jack Whitaker, MD
Collier Jordan, MD
James Hunter, Chief Executive Officer, Health Alliance Physician Hospital Organization
Casey Irish, RN, Performance Improvement Outcomes Manager, Mountain States Health Alliance
Rita Perkins, RN, Performance Improvement Outcomes Manager, Mountain States Health Alliance
Karen Cober, RN, Senior Strategic Service Unit Director, Mountain States Health Alliance Home Health Services
Lena Onks, LPN, Mountain States Health Alliance Home Health Services
Jane Andrews, Director of Medicare, Mountain States Health Alliance Home Health Services
Rick Newman, Senior Director, Mountain States Health Alliance Medical Call Center
Sherry Franks, RN, Nursing Supervisor, Mountain States Health Alliance Medical Call Center
Donna Henderson, RN, Resource Nurse, Mountain States Health Alliance Medical Call Center
Doug Click, Decision Support Analyst, Mountain States Health Alliance

• Post-enrollment CHF-related Emergency Department visits to JCMC
• Post-enrollment CHF-related inpatient readmissions to JCMC
• Post-enrollment CHF-related inpatient admissions to JCMC
• ALOS for CHF-related readmissions to JCMC

The changes noted below were identified, designed, implemented and refined in order to achieve the most efficient and effective process for referring, enrolling, monitoring, managing, improving, tracking, and reporting on the outpatient care of CHF (Congestive Heart Failure) patients.  These changes were implemented while coordinating the care delivery process across several boundaries — hospital/inpatient, self- and/or home care, telemonitoring and medical call center, and with the primary care physicians’ and cardiologists’ offices.

• Identified source for funding a pilot project on outpatient CHF management (HAPHO)
• Identified gaps in post-hospital, outpatient care of CHF patients
• Identified key individuals within the organization (HAPHO and MSHA) —  i.e., the "champions" to design and implement an outpatient CHF management program
• Defined criteria for patient participation/enrollment in the program
• Developed a comprehensive, coordinated, multidisciplinary management plan for CHF outpatients using evidence-based best practices
• Designed, identified and provided a comprehensive patient education program and materials for CHF (basic disease information — causes, symptoms, etc.), medications, and the importance of lifestyle issues (e.g., salt and fluid intake, medication compliance, weighing daily)
• Identified a telemonitoring partner (Heart Alert, Inc., a Georgia-based telemonitoring and clinical information management company)
• Educated home health and call center staff specifically on CHF and related best practices
• Developed comprehensive "standing orders" to facilitate patient enrollment in the program
• Reviewed, revised, and developed pharmacologic intervention protocols which can be customized per a physician’s preferences and/or an individual patient’s needs
• Provided direct delivery and pick-up or faxing of standing orders to/from physicians’ offices
• Provided a dedicated CHF phone line — allowing case managers and physicians to refer patients to the program with a single phone call
• Centralized communication for and coordination of the CHF program (clinical services, database management) through the medical call center
• Informed and educated internal customers (primary care physicians, cardiologists, case managers, call center and home health nurses) about the "Outpatient CHF Management Program"
• Identified and maintained a personal contact for each patient within home health and the call center
• Provided to patients, at no cost, telemonitoring equipment or standard scales for weighing
• Provided a comprehensive home health assessment, at no cost, to patients who did not qualify for covered home health services
• Delivered, set up, and educated patients about telemonitoring equipment
• Coordinated patient education about CHF, medications, lifestyle issues (salt and fluid consumption, daily weight monitoring, etc.) among telemonitoring center, home health and medical call center
• Provided information and guidance to patients about their other disease processes or health-related questions using a database of standardized call center protocols
• Communicated with physicians: (a) regarding interventions and/or significant or unresolved CHF symptoms or signs as they occurred; and (b) via monthly summary reports for each patient
• Intervened with patients whose signs (weight, blood pressure) exceeded pre-determined variance thresholds and/or whose symptoms suggested overt or impending decompensation of their CHF through adjustment of their medication(s) and reinforcement of lifestyle compliance issues
• Developed an automated daily report to identify any significant events (i.e., emergency room visits or hospital admissions) for participants
• Developed physician and patient information materials (e.g., brochures, posters, laminated business cards with information about the program, magnets with contact information)
• Intervened with reluctant patients and families to explain and support their participation
• Coordinated the transfer of individualized care oversight from home health to the medical call center upon expiration of home health services
• Scheduled weekly operational meetings between home health and call center staff for review of patients’ status and direct communication about and resolution of any problems related to the CHF program

Implementing a comprehensive and well-coordinated outpatient CHF management program has been instrumental in reducing acute care events (ED visits, inpatient admissions, and ALOS).  The process and outcomes have been shared throughout the region with health care and community leaders, employers, and payers resulting in an ongoing trial of the program with one of the top three payers (based on number of covered lives) in the region.

• Identify and involve the right people — representative of all aspects and phases of the project.  This brings the best and most appropriate depth and breadth of knowledge and perspective to the planning and implementation of the project.
• Engage, from the outset, a leader or facilitator who is familiar with and knowledgeable about PI (performance improvement) processes to "do it right" the first time.
• Learn and adapt from the successes (and failures) others who have "gone before you" — those who fail to learn from history are destined to repeat it.
• Incorporate rapid-cycle change processes to facilitate early detection ad correction of problems (PDCA).
• Educate, inform, and communicate frequently to anyone and everyone directly or indirectly involved in or impacted by the project using a variety of methods.
• Use your "champions" to promote the process and project — leverage the respect, recognition, and voice they have within and beyond the team and organization.
• Encourage, recognize, and reward "mini-PI" efforts by individuals and small groups within the team, successful or not — there are lessons to be learned either way — "ready, fire, aim."
• Gain the support and commitment of the organization’s leadership — your success (and theirs) may depend on it!
• Simplify and streamline the processes as much as possible — the easier it is to do, the more likely it will be done (i.e., the path of least resistance).
• Share the process and outcomes outside the organization — it will enhance the image of the organization, may result in feedback for improvements not previously considered from within, and may result in expanded or new business opportunities.

Daniel J. David, MD, Medical Director
MSHA Physician Hospital Organization
daviddj@msha.com