Heart Failure Disease Management

ESSENTIA HEALTH’S EXPERIENCE IN SCALE UP AND SPREAD

MODEL OF CARE

• MULTIDISCIPLINARY DISEASE MANAGEMENT PROGRAM• PATIENTS MANAGED BY NURSE PRACTITIONERS/PHYSICIAN

ASSISTANTS IN COLLABORATION WITH CARDIOLOGIST• RN’S DO EXTENSIVE EDUCATION ON DIET/MEDICATIONS• PATIENTS SCHEDULED FOR CLINIC VISITS THROUGH OUT THE YEAR

(7 VISITS FIRST YEAR, 4 VISITS FOLLOWING YEARS) AS WELL AS PRN

• OUTCOMES:• 3-5% 30 DAY READMISSION RATE• 90-96% OF PATIENTS ON GUIDELINE DIRECTED MEDICATIONS • LOWER phq-9 (DEPRESSION) SCORES AFTER ENTERING PROGRAM• HIGH PT SATISFACTION• MILLIONS OF $$ SAVED PER YEAR IN COST AVOIDANCE• CURRENTLY MANAGE 1400 PATIENTS IN PROGRAM ACROSS ESSENTIA

FOOTPRINT

SPREAD WITHIN SYSTEM

• DEVELOPED PROGRAMS AT SATELLITE CLINICS AROUND REGION – VIRGINIA, MN; DEER RIVER, MN; HAYWARD, WI; ASHLAND, WI; SPOONER, WI

• MODIFIED MODEL IN SUPERIOR, WI; INTERNATIONAL FALLS, MN

• DEVELOPED PROGRAM IN NEWLY AQUIRED HEALTH CARE SYSTEM – BRAINERD, MN

• IN PROCESS OF DEVELOPING PROGRAM IN FARGO, ND

CHALLENGES/SUCCESSES OF SPREAD

• RECOGNITION THAT EACH SITE HAS DIFFERENT CULTURE/POLITICAL PRESSURES

• MANAGING PROGRAM AND STAFF FROM AFAR• KEEPING REGIONAL STAFF UP TO DATE ON DAILY COMMUNICATION

– USE OF TELEHEALTH/VIDEO CONFERENCE• FLEXIBILITY TO ALLOW SITE SPECIFIC DIFFERENCES WITHOUT

COMPROMISING BASIC MODEL• NOT ALL SITES HAVE THE SAME RESOURCES AVAILABLE (DIETICIAN,

PHARMACY)• FINANCIAL AND CREDENTIALING CHALLENGES ARE DIFFERENT AT

EACH SITE BASED ON PAYER/STATE REGULATIONS

PATIENT STORY

• PATIENT WOULDN’T DRIVE ACROSS BRIDGE FROM SUPERIOR WI TO DULUTH

• STARTED OUTREACH IN SUPERIOR, WI• DECREASED MONTHLY ADMISSIONS TO 0 ADMISSIONS AFTER

ENROLLMENT• IMPROVED FUNCTIONAL STATUS