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BUSINESS PLAN: HEART FAILURE OUTPATIENT SERVICES

Business Plan: Congestive Heart Failure Outpatient Services Clinic

Simonette P. Elgert

Siena Heights University

LDR 609- Health Care Systems Management

October 29, 2013

Dr. John Fick

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CONGESTIVE HEART FAILURE OUTPATIENT SERVICESA BUSINESS PLAN OUTLINE

Today in the United States chronic disease is the major cause of disability, is the main reason

why people seek health care, and consumes 70% of healthcare spending. With chronic disease,

the patient’s life is irreversibly changed. Neither the disease nor its consequences are static. They

interact to create illness patterns requiring continuous and complex management. Furthermore,

variations in patterns of illness and treatments with uncertain outcomes create uncertainty about

prognosis. The key to effective management is understanding the different trends in the illness

patterns and their pace. The goal is not cure but maintenance of pleasurable and independent

living (Holman & Lorig, 2000).

Executive Summary

Congestive Heart Failure (CHF) is a chronic disease caused by the inability of the heart

to pump enough blood and oxygen to support other organs. According to Centers for Disease

Control and Prevention (CDC), there are around 5.7 million people in the United States who

have heart failure. It is the cause of more than 55,000 deaths per year and the contributing cause

in more than 280,000 deaths (1 in 9) in 2008. CHF costs the nation 34.4 billion each year

including the cost of health services, medications and lost of productivity. Early diagnosis and

treatment can improve quality of life and life expectancy. Treatment usually involves taking

medications, reducing salt in the diet and getting daily physical activity (www.cdc.gov).

The number of persons with chronic illness is growing at an astonishing rate due in part,

to the aging of the population, lifestyle habits, such as increased incidence of obesity, and the

greater longevity of persons with many chronic conditions. Heart disease is the number one

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http://www.cdc.gov/


cause of death in Michigan accounting for 23,044 deaths and 2,346 deaths in the city of Detroit

alone in 2010 (www.mdch.state.mi.us). Although heart failure is a serious condition that

progressively worsens overtime, there are a number of treatments that can relieve symptoms and

stop or slow the gradual worsening of the condition. The goals of the therapy are:

a. Relieve symptoms and improve quality of life

b. Slow the disease progression

c. Reduce the need for emergency room visits and hospitalization

d. Help people live longer

It is the intent of this business plan proposal to contribute to the goals of therapy for

patients with Congestive Heart Failure (CHF) through the provision of patient-centered approach

to heart failure care, continuity of care post hospitalization and most importantly, care

coordination in an outpatient setting. It is also the goal of CHF Outpatient Services Clinic to

decrease hospital readmission, decrease cost per case and improve the quality of care and

satisfaction for this patient population.

Proposal

Congestive Heart Failure Outpatient Services Clinic will operate within the outpatient

department of the hospital and will service patients diagnosed with heart failure. Criteria for

admission into the clinic include but are not limited to: left ventricular ejection fraction (LVEF)

of <40%, New York Heart Association (NYHA) class II-IV as determined by multigated

acquisition scan, more than one hospital readmission in the past year with heart failure (Henrick,

2001). Referrals will come from the physicians, nurses and or patients. As stated above, the

goals of treatment for heart failure are symptom management, treatment of the underlying

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causes, lifestyle changes and medications. The identified patients will be assisted in most aspects

of treatments in order to manage symptoms and reach the goal of slowing the disease progression

and decrease hospital admissions/readmissions. The Heart Failure Society of America (HFSA)

proposed guidelines will be used as the clinic workflow consisting of the following components:

a. Disease Management – which will include comprehensive education and

counseling on self-care, financial support, and availability of resources.

b. Functional Assessments – will utilize New York heart Association (NYHA) Class

Function status assessment on every visit, 6-minute walk test (6MWT) on

baseline and during risks assessments, Cardiopulmonary exercise testing to set a

baseline.

c. Quality of Life Assessments – will be completed and documented at baseline and

status change to include symptoms assessment and health related quality of life.

d. Medication Therapy and Drug Evaluation – will include medical therapy that

follows established HF medication guidelines such as Angiotensive converting

enzyme (ACE) inhibitors, beta blockers, diuretics, potassium and magnesium

supplements, digoxin and other anti-arrhythmic drugs.

e. Device Evaluation – will include a process to evaluate and document devices such

as ICDs, care coordination with electrophysiologists and a system in place to

address alerts and recalls of devices.

f. Nutritional Assessment – will include nutritional assessment and education by a

dietician focusing on those patients with co-morbidities and tracking of nutrition

metrics such as weight and body mass index.

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g. Follow- up – standardized follow-up appointment within 7-10 days at the clinic

post hospitalization; preferably after being seen by the cardiologists. Maintenance

visits monthly.

h. Advance Planning – include assistance for patient to determine both medical and

non-medical care the patient will receive before the condition preclude them from

making decisions.

i. Communication – provision of open communication between patient and

provider.

j. Provider Education – will include mechanisms to track and ensure provider

competencies are up-to-date.

k. Quality Assessment – will be measured through outcomes (readmission rates,

survival rates), processes (weight tracking, patient education) and structural

components (registries and reporting to regulatory bodies)

(www.nursingeconomics.net).

A cardiology Nurse Practitioner (NP) or a Clinical Nurse Specialist (CNS) will be the

primary care provider under the supervision and in consultation with the chief of

cardiology. Aside from the NP/CNS and physician, other members of the team will

include:

a. Registered Nurse – will assist the NP with assessment and providing education.

b. Dietician – will assist with nutritional needs and education.

c. Social Worker – will assist with social needs affecting ability to care for self or

follow treatment regimen.

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http://www.nursingeconomics.net/


d. Patient Care Technician – will assist with vital signs monitoring, exercise or

phlebotomy.

e. Unit Clerk – will assist with appointments, scheduling and coordination with

other physicians

The proposed site is the currently vacant Rapid Admission Unit (RAU) located on

the West side of the hospital on the first floor. The clinic will operate 5 days a

week, Monday to Friday between the hours of 8:00 am to 4 pm not including

holidays. Patient visits will vary ranging from 1-2 times a week or every 6 months

depending on how managed the patients symptoms are.

Market Analysis

Heart failure patients are of Medicare age. It occurs most frequently in those over

age 60 (www.hopkinsmedicine.org). But the services that will be provided by the heart failure

clinic will be available to any patients who meet criteria for admission to the clinic regardless of

age, gender and racial origin. The service areas will be consistent with the hospital’s defined

radius of service. The clinic will be available to patients in the tri-county areas of Wayne,

Oakland and Macomb and within the 20-mile radius from zip code 48236. The availability of the

clinic services will be marketed to all the physicians and hospitalists for possible referrals. The

referrals may be initiated by any physicians, doctors offices, case managers and ER staff. The

clinic is accessible through the west entrance of the hospital and is on the first floor.

The greatest opportunity for this service will be for those patients who are

discharged from the hospital with a heart failure diagnosis. The discharge planner will be

responsible to make the referral and secure an appointment prior to the patient’s departure by

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contacting the clinic. Appointments will be made within 7-14 days preferably after the patient

has been seem by the cardiologists. The clinic NP/CNS will follow up with the patient and

coordinate with the home health care agency responsible for the care of the patient post

hospitalization. The heart failure clinic will support the needs of the patient population suffering

from this condition. Although there is no cure for heart failure, it is possible for patients to enjoy

better health with disease management, which will be provided by the heart failure clinic. The

goal is to keep the patients from having to be admitted as a result of increased symptoms related

to poor compliance with treatment. After much research and review of the requirements for

Certificate of Need (CON) through The Michigan Certificate of Need Program published in 2005

by the Citizens Research Council of Michigan, the proposed heart failure clinic does not require

one. The clinic is considered an extension of the hospital’s outpatients services and Clinical

Decision Unit (CDU).

After extensive research of the services our immediate competitors (Henry Ford,

Beaumont) provide through their websites, both do not offer the same services as proposed.

However, the John D. Dingell VA Medical Center, located on 4646 John R. Street, Detroit

Michigan 48201, about 10.28 miles from the St. John Hospital and Medical Center has two heart

failure clinics which are run in conjunction with a pharmacy-drug titration clinic. Their clinic

provides care for newly diagnosed CHF patients, those with recent hospitalization with CHF as

the primary diagnosis or those with frequent CHF admissions (www.detroit.va.gov). VA

Hospital is not considered a competition to the proposed clinic. Their health care services are

limited to the veterans and military service members.

There is very low to no risk involved in this proposed heart failure clinic. Studies

have shown that on a small scale, NP/CNS-run clinic for heart failure has demonstrated positive

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http://www.detroit.va.gov/


outcomes in the management of these patients. In the very near future advanced practice nurses

will become primary care providers (Henrick, 2001). As the era of Accountable Care

Organizations (ACOs) is ushered in and many provisions of the Affordable Care Act (ACA)

begin to be implemented, nurses will play a fundamental role in the transformation of the

healthcare system. The changes in nursing will enhance the success in an increasingly

competitive and financially difficult environment (Rowe, 2013). Advanced practice nurses play

an important role in the treatment of heart failure through their education, nurses approach these

patients holistically and integrates many aspects of care (Henrick, 2001).

Presence in the market requires that services be positioned vis-à-vis competing

services. Positioning depends upon the strengths and weaknesses of the organization and the

issues in the external environment (Swayne, Duncan & Ginter, 2008, p. 279). For the proposed

clinic, the appropriate positioning strategy is cost leadership, which uses services that are simple

to produce (p. 281). The market entry strategy appropriate for this plan is internal venture

strategy, which is the establishment of an independent entity within an organization to develop

products or services (p. 228). This strategy allows the use of existing resources, which is how the

clinic will be designed. In order to gain success, the support of the physicians and staff to the

program are critical.

Internal Assessment

The St. John Providence Health System Strategic Focus are:

a. Patient Experience

b. Strategic Market Growth

c. Value Demonstration

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d. Associates/Physicians Engagement

e. Defined Population Management

The proposed heart failure clinic is in alignment with the defined population management

strategy. The target of this proposal is the CHF patient population disease management and the

goal is to decrease readmission rate, cost of care and improve quality of care and satisfaction.

Nursing, in partnership with the chief of cardiology will own the implementation of the

proposal. The sponsoring department’s strategies include:

a. Spiritually Centered Holistic Care

b. Improved Patient Experience

c. Patient Safety and Quality

d. Clinical Ladder

e. Shared Governance

f. Research

g. Magnet Pathway Journey

The concept of the heart failure clinic is in alignment with patient safety and quality, patient

experience and research. The plan is to gather data relating to how the clinic will help

improve disease progression and symptom management as evidenced by decreased

readmission rate of the heart failure patient population.

There is currently a process in place that is similar to this proposal at St. John Hospital

and Medical Center. Twice a week, there is a physician who comes in and sees patients

referred by the NPs. There is no formal process in place and there is no defined goal/purpose.

There is also no data gathering or tracking mechanism that could be used for data

management. The lead NP for cardiology is hoping to have a formalized heart failure clinic

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to support their efforts in trying to educate patients regarding care management post

hospitalization. In the meantime, education starts and ends in the hospital setting.

Heart Failure patients are usually referred to home care post discharge. The services that

they offer are limited and sometimes lacking due to visit restrictions. It is the hope that the

proposed heart failure clinic will bridge the gap in care in the outpatient setting.

St. John Hospital and Medical Center is well positioned to develop this service. First,

there is already an existing structure that would house the clinic. The location of the proposed

clinic is on the first floor adjacent to the emergency room and close to the clinical decision

unit (CDU). It is also close to a main entrance and parking structure. Second, there are

already potential candidates for the nurse practitioner, someone dedicated to the care of heart

failure patients. The organization also has the means of supporting the clinic through grant

money received from donors. There was a recent donation of four million dollars towards

cardiology projects. According to the chief of cardiology, the two hundred thousand dollars

interest yearly will be used to fund different cardiology initiatives. If the program is

successful in meeting its goals, a recommendation will be made to make this proposal

system-wide.

As mentioned earlier, nursing will take the lead on this proposal in collaboration with the

mid-level providers and the chief of cardiology. This will be an NP-run clinic, under the

direction of Dr. Lalonde. There will be a director sponsor, most likely, Laura Cadieux, since

she is over the cardiology division. The other team members will include a registered nurse,

dietician, a social worker/case manager, patient care technician and unit clerk. This proposal

will also be assigned a manager sponsor who will ultimately be responsible on the day-to-day

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operation of the clinic. Since the lead NP will focus on this project, the other mid-level

providers will have to cover some inpatients during rounding.

Below is an illustration of the proposed heart failure clinic workflow:

Patient Referral

Unit Clerk Nurse Practitioner

Readmission

Telephone follow-up

Education Referral

RN Clinic Admission SW

Symptom/Disease Management

Regular Follow -up

Non-compliance Goals achieved

Financial Analysis

As hospitals are faced with the relentless shift toward caring for only the

most acutely ill patients, organizations will be forced to develop more efficient,

efficacious, cost-minimizing, and evidenced based treatment paths in order to remain

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viable and competitive in the rapidly changing healthcare marketplace (Sieck, n.d.).

The proposed heart failure clinic is in response to the need of the organization to

manage chronic diseases and to decrease readmission rate. The demand for this kind

of service will increase from referrals due to high number of heart failure patients

who have multiple admissions due to poor symptom management. The higher volume

of patients seen in the clinic could reduce the amount of hospital admission.

The proposed physical location of the clinic is the vacant rapid admission unit.

The space set-up is usable and is appropriate for a clinic setting. It has a nursing

station, semi-private patient rooms, restroom facilities for both patients and staff and

conference room . There is ample space for a good weighing scale and an exercise

machine for assessment of endurance and tolerance to exercise. The amount of

renovation that will be required in order to make it functional is minimal. It will need

painting, scrubbing and re-arranging of furniture and hospital beds. It is already

equipped with a telephone line and a computer.

E-care will be used as source of patient information and admission history as well

as laboratory tests and other imaging results such as X-ray and CT scan. In the current

system, any patient encounters are added and reflected in our electronic medical

record (EMR), including outpatient tests. The clinic will follow the same path. There

will be a need to add the CHF clinic to our current list of service areas and possibly

add specific identifiers to the registration number. No major information technology

changes or upgrades have to occur. Aside from dedicating its own staff to the new

clinic and purchasing some equipment (weighing scale, exercise machine, copier, fax

machine) and adding two additional computer terminals or portable devices such as

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an I-Pad, there will be no major resources needed in order to become operational.

There will be no pricing strategy that will be pursued. The services that will be

provided in this clinic will be compensated as part of values-based purchasing as set

forth by the different payers. Below is the Financial Assumption for the proposed

CHF Clinic.

Assumptions

Volume Assumptions 1,300 (based on 2012 FYTD CHF Admissions

Hours of Operation Monday – Friday8:00 am – 4:00 pmexcluding holidays

Revenue/Case Dependent on Medicare payments. If the hospital readmission rate is decreased, 1-2% of penalty will be avoided (see below explanation)

Start-up Expense $5,000 – site renovation$10,000 – equipment purchase expense including I.T.

Staffing/FTE Job Class:Nurse Practitioner – 1.0 FTERegistered Nurse – 1.0 FTEPatient Care Technician – 1.0 FTE (phlebotomy trained)Unit Clerk – 1.0 FTEDietician – 0.0 FTE (rotation)Social Worker – 0.0 FTE (rotation)

Rate of Pay (entry level) Job Class:Nurse Practitioner – $35/hourRegistered Nurse – $28/ hourPatient Care Technician – $13/ hourUnit Clerk – $11/ hourDietician – $18/hourSocial Worker - $14/hour

Other Operating Expense TBD

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The true revenue that will be realized in this proposal will be in the form of cost

savings and higher reimbursement to the hospital. First, indirect savings will be

obtained from saved bed days and reduction of aggressive treatment (if readmission is

avoided). Second, it will be in the form of no dollars lost. The average reimbursement

is $5759, which often does not receive sufficient reimbursement to cover the costs of

care for the CHF patient. The financial break-even point for CHF is about 5 days but

the average length of stay is greater than 5 days. The average dollars lost is

approximately $2104 per patient (Sieck, n.d.). With the new Patient Protection and

Affordable Care Act (PPACA) legislation, hospitals are vulnerable to more losses.

They could become fully financially responsible for the care of such patients (Sieck,

n.d.). The goal of the proposed CHF clinic is to avoid those losses.

Implementation Plan

In order to have sufficient time to completely plan the specifics of this

proposal, and to not compete with some major undertakings that are going to take place in

the next 2-4 months. The proposed implementation date is April 7, 2014. The following

timeline will be followed:

Business Plan: Congestive Heart Failure Clinic

Primary Sponsors: Dr. Thomas Lalonde, Chief of Cardiology Laura Cadieux, Director of Nursing, Cardiology Division

Members: Mary Jo Pitera, Lead Cardiology Nurse Practitioner Simonette Elgert, Clinical Nursing Manager, 4 North Appointee from Social Work/Case Management Appointee from Nutritional Services Appointee from Registration/Outpatient Services Jim Wild, Maintenance and Engineering Appointee from Finance

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Dave Poynter, Information Technology

Optional: Tomasine Marx, V.P. of Finance Board Member Representative Donor Representative Additional Cardiologist Representative Lead Director Clinical Decision Unit Manager Quality Department

Date/Time What Who Where

November 2013 Initial Meeting withSponsors and

members; Appointment of representatives; division of labor

along with timelines

Sponsors andAll Members

Cardiac Cath Lab Conference Room

November 2013Meeting with Jim Wild in order to

discuss specifics of needed site

updates/Meeting with IT

SponsorsJim Wild

Simonette ElgertMary Jo PiteraDave Poynter

Cardiac Cath LabConference Room

December 2013 Workflow Meeting/Finance Considerations

SponsorsAll Members


January 2014(will meet every 2

weeks)

Creation of Policies and Procedures;

Purchase of Equipment

All Members Cardiac Cath Lab Conference Room

February 2014(will meet every 2

weeks)

Appointment of Staff/Hiring;

Finalization of Process

SponsorsAll Members


March 2014(will meet weekly)

Meeting with Finance and Registration for

finalization of processes;

SponsorsAll Members


April 2014 Go Live SponsorsAll Members

CHF ClinicConference Room

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The objective of the proposed CHF clinic is to serve patients diagnosed with heart

failure, to assist them towards slowing down the disease progression. The goal is to

decrease the overall readmission rate by symptom management, education, counseling

and follow-up. In 2012, St. John Hospital and Medical Center admitted 1,294 patients

with CHF as the principal diagnosis. 6.41% of those patients were readmitted to the

hospital within 15 days of discharge and 11.05% were readmitted within 30 days of

discharge (Juchartz, 2013). The goal is to decrease both rates by at least 5% in the first

year and 10% in the subsequent years. The workflow and progress will be monitored

closely. Opportunities for improvement will be identified. The first few days will be

critical. The team will come together after the first week and will find ways to improve

on some of processes breakdown. Re-appointment of tasks may be necessary. Progress

report will be made available to the sponsors and to all members of the team. Regular

meetings will be called until the workflow is smoothen out. Data collection will start

immediately and measures will be monitored by the Quality Department for Clinical

Excellence reporting.

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References

Centers for Disease Control and Prevention. (2013, July 26). Heart Failure Fact Sheet. Retrieved

from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm

Citizens Research Council of Michigan (2005). The Michigan Certificate of Need Program.

Retrieved from http://www.crcmich.org/PUBLICAT/2000s/2005/rpt338.pdf

Heart and Vascular Institute. (n.d.). Congestive Heart Failure. Retrieved from

http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/

conditions/congestive_heart_failure.html

Henrick, A. (2001). Cost-effective outpatient management of persons with heart failure.

Progress in Cardiovascular Nursing, 16(2). Retrieved from

http://www.medscape.com/viewarticle/407751_2

Hines, P., Yu, K., Randall, M. (2010, March-April). Preventing heart failure readmissions: is

your organization prepared?. Nursing Economics, 28(2). Retrieved from

http://www.nursingeconomics.net/ce/2012/article28074074.pdf

Hodge, T. (2002, April 18). Improving chronic disease management: a powerful business case

for congestive heart failure. Retrieved from http://

www.health.gov.bc.ca/library/publications/year/2002/congestive_plan.pdf

Holman, H., Lorig, K. (2000, February 26). Patients as partners in managing chronic disease.

BMJ, 320(7234), 526-527.

Juchartz, S. (2013). Clinical excellence reporting. (E-mailed report). Accessed on 2013,

September.

Longest Jr, B. B., & Darr, K. (2008). Managing health service organizations and systems (5th

ed). Baltimore, MD: Health Professions Press, Inc.

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http://www.health.gov.bc.ca/library/publications/year/2002/congestive_plan.pdf

http://www.nursingeconomics.net/ce/2012/article28074074.pdf

http://www.medscape.com/viewarticle/407751_2

http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/congestive_heart_failure.html

http://www.hopkinsmedicine.org/heart_vascular_institute/conditions_treatments/conditions/congestive_heart_failure.html

http://www.crcmich.org/PUBLICAT/2000s/2005/rpt338.pdf

http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm


Michigan Department of Community Health. (n.d.). Deaths and crude death rates for the ten

leading causes of death, Detroit City, Wayne County and Michigan residents, 2010 and

United States residents, 2008. Retrieved from

http://www.mdch.state.mi.us/pha/osr/chi/Deaths/leadUS/Mcdus.asp?

Dxld=3&CoCode=1749

Rowe, J. W. (2013). Transitions in nursing present challenges and opportunities for hospitals.

Future Scan 2013: Healthcare Trends and Implications 2013-2018. p. 15.

Sieck, S. (n.d.). The economics and reimbursement of congestive heart failure. Short Stay

Management of Acute Heart Failure. pp. 9-32.

St. John Providence Health. (n.d.). Nursing strategic plan: 3-year. (Handout).

Swayne, L. E., Duncan, W. J., Ginter, P. M. (2008). Strategic management of health care

organizations (6th ed). San Francisco, CA: Jossey-Bass

U.S. Department of Veterans Affairs (n.d.). Healthcare Services: Cardiovascular Service Line.

Retrieved from http://www.detroit.va.gov/services/Cardiovascular_Service_Line.asp

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http://www.detroit.va.gov/services/Cardiovascular_Service_Line.asp

http://www.mdch.state.mi.us/pha/osr/chi/Deaths/leadUS/Mcdus.asp?Dxld=3&CoCode=1749

http://www.mdch.state.mi.us/pha/osr/chi/Deaths/leadUS/Mcdus.asp?Dxld=3&CoCode=1749

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