standardization of heart failure care through a cross-hospital … · 2018-10-08 · heart failure...

Standardization of Heart Failure Care Through a Cross-Hospital Effort

Matthew Oberhardt, PhD Kelly Axsom, MDKumudha Ramasubbu, MD

October 2, 2018

Disclosures

§ Matt Oberhardt, PhD– None

§ Kelly Axsom, MD– Consultant Abbott

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NewYork-Presbyterian Healthcare System

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Heart Failure is a Syndrome

Complex clinical syndrome due to structural or functional cardiac disorder impairs the ability of heart to fill or pump

The heart is unable to meet metabolic demands leading to symptoms of fatigue, shortness of breath and volume overload

Heart Failure

Incidence Treatments NYHA Class

5-year Survival

A ~65 million pts/year High Risk of HF Prevention none 97%B ~10 million pts/year Asymptomatic Medications NYHA I 96%C ~5 million pts/year Symptomatic Medications

Procedures NYHA I-IV 75%

D ~200,000 pts/year End-Stage Specialized Care NYHA IV 20%Yancy CW, et al. Circulation. 2013;128: e240-e327 .

Heart Failure – Population Health Impact

§ Estimated 26 million worldwide– US 5.8 million

§ Leading cause for health care access– 1 million admissions/year US– 12 million/year office visits US

§ US $32 billion annual cost– 2030 estimated $70 billion annually

§ 50% mortality 5 years of diagnosis

§ Multi-morbid

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0

2

4

6

8

10

12

1991 2000 2037H

eart

Fai

lure

Pat

ient

s in

the

US

(Mill

ions

)

Fonarow et al JACC 2007;50:768-77.Van Deursen et al. Europ J Heart Failure. 2014. 16:103-111.

1% 11%

33% 55%

Medicare Beneficiaries 2010

No comorbidities

1-2 comorbidities

3-4 comorbidities

≥5 comorbidities

CMS: Hospital Compare Focus on Quality

2002 2005 2008 2009 2009 2011 2012 2013 2016

Medicare.gov; Hospital Compare, www.cms.gov

The Ask

January 2017 Executive Steering Committee• Dr. Corwin (President and Chief Executive Officer) • Dr. Forese (Executive Vice President and Chief Operating Officer)

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1. Understand heart failure protocols & programs at each of the 8 NYP hospitals2. Develop referral criteria & regional program strategies 3. Develop standards of care for heart failure

à Help patients live longer, live better

The Ask – NewYork-Presbyterian 2018 Kick-Off Goals

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The Process Improvement Challenge

Clinician engagement

Goals of leadership

Physicians engaged primarily in clinical work don’t think this way

Fee For Service

Large Hospital NetworksHospital Systems as the Insurer

Value Based Care

The Stakeholders

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Multidisciplinary, clinician-led group Leader: Shunichi Homma, MD CMO, Columbia Faculty Practice Organization

Hospital Based Clinicians Transitions of CareNYPH Support

Weill Cornell§ Dr. Evelyn Horn§ Dr. Maria Karas

Columbia§ Dr. Nick Homma§ Dr. Paolo Colombo§ Dr. Kelly Axsom

Lower Manhattan§ Dr. Yuliya Kats

Allen § Dr. Gerald Neuberg

Queens§ Dr. David Slotwiner§ Dr. Alex Volodarskiy

Lawrence§ Dr. Tony Mercando§ Dr. Douglas Hart

Hudson Valley§ Dr. Howard Tarkin

Methodist§ Dr. Kumudha

Ramasubbu

NYP§ Dr. Deepa Kumaraiah (SL)§ Carolyn Halik (SL)§ Sonia Bandrowski (SL)§ Eileen Kieran (SL)§ Julie Mirkin (CM)§ Matthew Oberhardt (Analytics)§ Denise McLaughlin (Analytics)§ Harry Sherman (Marketing)ACO§ Dr. Paul Casale

ACN§ Claudia Beck

RN and Care Management

§ Caryn Donocoff§ Lena Ileodes§ Jeanette Melchor§ Cathy Halliday§ Deena Schmidt§ Tim McGarvey§ Lisa McIntyre§ Theresa Quarless§ Jenny Li§ Brigid§ Darlene Adaire§ Virgina Bjorton

First Step: Inventory Heart Failure Care at NYP

INPATIENT Lawrence HudsonValley Queens Milstein Methodist Allen Weill

CornellLower

Manhattan

Private Internist ü ü

Hospitalist / Medicine ü ü ü ü ü ü ü ü

Private Cardiologist ü ü ü ü ü ü ü

On-Call Cardiologist ü ü ü ü ü ü

Cardiology Consult ü ü ü ü ü ü ü ü

Heart Failure Specialist ü ü ü

HF Discharges (2016 MS DRG) 479 374 711 827 1080 357 640 176OUTPATIENT

NYPMG Primary Care Physician ü ü ü ü ü ü ü ü

CD/WC Primary Care Physician ü ü ü ü ü ü

NYPMG Cardiologist ü ü ü ü ü ü

CD/WC Cardiologist ü ü ü ü ü ü

Heart Failure Cardiologist ü ü ü

HF Nurse Practitioner ü ü ü (RN) ü

Other (non-affiliated providers) ü ü ü ü ü ü ü ü

Leader: Carolyn Halik

Inpatient Guidelines

Website

Dashboard

Regional Support

OutpatientGuidelines

Transitions of Care

NYP HF Standardization


Creating Clinical GuidelinesIn-PatientTransitions of CareOut-Patient

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Standardizing Heart Failure: In-Patient Guidelines

§ Core group of 3§ Bigger sub-group of 6§ Weekly calls§ Required hospital-specific feedback

– Physician Leaders– Residents/PA/RN/NPs/Non-Cardiologist– Pharmacy

§ Created 7 cards with identical processes and site specific content

18Committee Leaders: Gerry Neuberg, MD; Kelly Axsom, MD; Eileen Kieran

Aug2017

Jan2017

April2017

Feb2017 Initial draft Final

Initial Draft of Guidelines

19Leaders: Evelyn Horn, MD; Paolo Colombo, MD; Kelly Axsom; MD

AHA Get With The Guidelines DataBetter Survival:- Advanced Heart Failure- Cardiac Surgery - Percutanenous Coronary Interventions

Pandey et al JAMA Cardiol 2018 epub

The Joint Commission:BEST PRACTICES LIBRARY

Standardizing Heart Failure: Transitions of Care

§ Inventory– Practice patterns varied greatly– Some sites without resources

§ Core group of 3 providers § Bigger sub-group of 6§ Weekly calls§ Required feedback and input from committee members

§ Biggest challenge is real-time patient identification

21Committee Co-Chairs: Julie Mirkin, RN, PhD; Kelly Axsom, MD

Aug2018

Jan2017

Nov2017

Jan2018

May2018First meeting Draft 1 Draft 8 Final

Medical Literature: Transitions of Care HOT TOPIC

Jencks et al NEJM 2009;360:1418 Hernandez et al JAMA 2010.303:1716Van Spall et al Eu Heart J. 2017. 19:1427-1443

• 30-Day Readmissions – linked to post discharge visits• 30-day readmission rates are lower if outpatient visit within 7-d of discharge• No outpatient visit within 30-d associated with >50% readmission rate

• Mortality Reduction – Disease Management Clinics and Home Nursing Visits

23Transitions of Care Guideline Committee: Virgina Bjorton RN (Allen), Lena Ileodes RN (NYP); Caryn DonocoffRN (ACO)

Standardizing Heart Failure: Outpatient Guidelines

§ Core group of 3§ Bigger sub-group of 6§ Twice monthly calls§ Individual hospital feedback

– Physician – Outpatient providers– PA/Residents/Internal Medicine

§ Currently defining dissemination process

Committee: Gerry Neuberg, MD; Kelly Axsom, MD; Kumudha Ramasubbu MD; Paolo Colombo; MD; Evelyn Horn, MD; Eileen Kieran

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Oct2018

Jan2017

March2018

April2018First meeting Draft 1 Final

25IN PROGRESS

Roll Out Planned for Oct 2018

Weill Cornell Columbia Lawrence

Hudson ValleyLMH Queens Brooklyn

MethodistThe Allen Hospital

Evelyn Horn, MD & Maria

Karas, MD

Paolo Colombo, MD & Kelly Axsom, MD

Tony Mercando,

MD and Douglas Hart, MD

Howie Tarkin, MD

Yuliya Kats, MD

David Slotwiner,

MD

Kumudha Ramasubbu,

MD

Gerald Neuberg,

MD

David Ramos Group

Mel Weiss Group

Warren Rosenblum, MDAinat Beniaminovitz, MD

Columbia Doctors

Change Management – Can Be Difficult

Distribution & Communication

Success measured by - Frequency of request of materials and updates- Dashboard measurements

Building a Heart Failure Dashboard

27Leaders: Matthew Oberhardt, PhD, Denise Mclaughlin, , Natalia Goldenberg

Designing a Heart Failure Dashboard

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• Incorporate metrics the clinicians identify

• Design tool that is sufficiently flexible, specific, and powerful

• Negotiate between feasibility (the ‘wish list’) and practicality• Our data is siloed and not always consistent!


• Incorporate metrics the clinicians identify

• Design tool that is sufficiently flexible, specific, and powerful

• Negotiate between feasibility (the ‘wish list’) and practicality• Our data is siloed and not always consistent!

Ø Drugs upon discharge• beta blockers?• ACEI/ARB/ARNI?

Ø Follow-up visit within 10 days?Ø 30-day post-discharge Mortality?Ø 30-day readmission to any facility?

Records inconsistent in EHR…

Data not available


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Volume

Mortality

LOS

ReadmissionHACS

Clinicalareas/procedures

Drilldownfilters


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Includes:

• Filters• Volume• Mortality• 30-day readmission, HF• 30-day readmission, all • 60-day readmission, all• Associated diagnoses:

o Ventricular tachycardiao Demand ischemiao Myocardial infarctiono Atrial fibrillation/flutter

• Follow-up appointment• MRNs of selected patients


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Includes:




Heart Failure patients broken into 6 categories:• HF – all• HFrEF• HFpEF• EF unspecified• Cardiogenic shock• HF with pulmonary hypertension


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Includes:




Validation

• During construction: vet each ICD code & clinical element with clinicians

• Internal validations of dashboard by unit tests

• Validation against Vizient data

• Validation by clinician chart review

Validation

Automated?

• During construction: vet each ICD code & clinical element with clinicians

• Internal validations of dashboard by unit tests

• Validation against Vizient data

• Validation by clinician chart review

Validation: Clinician Chart Review

Ø Required strong cooperation and buy-in

Ø Spoke to a clinician from each hospital on the phone

Ø 170 checks; 17 discrepancies

Ø Guided several revisions in dashboard logic

MRN Hospital AdmitDate DischargeDate metric val_dashboard val_trueXXX LMH XXX XXX Followup_HF N YXXX LMH XXX XXX Followup_HF N YXXX LMH XXX XXX Followup_HF_10d Y NXXX LawrenceHospital XXX XXX HF_Acute_Visit Y NXXX LawrenceHospital XXX XXX HF_Acute_Visit Y NXXX NewYorkMethodist XXX XXX HF_EFStatus_Visit HFrEF HFpEFXXX Allen XXX XXX HF_MI N YXXX LawrenceHospital XXX XXX HF_MI N YXXX LawrenceHospital XXX XXX HF_MI N YXXX LMH XXX XXX HF_MI Y NXXX LMH XXX XXX HF_MI N YXXX NewYorkMethodist XXX XXX HF_MI N YXXX NewYorkMethodist XXX XXX HF_MI N YXXX NewYorkMethodist XXX XXX HF_MI N YXXX Queens XXX XXX HF_MI N YXXX LMH XXX XXX HF_VT N YXXX Queens XXX XXX HF_VT Y N

Discrepancies:

Clinical Dashboards vs. Leadership Dashboards

LeadershipDashboard:Infonet à Executive portal(topright)à ClinicalLeadership Dashboard

• Usefulforbusiness-overview• Designedforgenerality;nottailoredtoclinicalareas• Cohortsbasedonbroad(DRG)categories• Doesnot includeclinicalareaspecificdiagnoses orfilters

ClinicalDashboards(e.g.,HeartFailureDashboard):data.nyp.orgà Department-specific dashboardsà CardiacandCardiacSurgery

• Usefulforclinicalmetrictracking• Tailoredtospecificclinicalareas(HFsofar;othersinproduction)• Cohort identifiedbyprocedureand/ordiagnoses• Includescomplications&clinicallyimportantfilters

Determining Acuity

• Noticed (incorrect!) drop 2016à2017 when applying ‘primary Dx is acute’ filter

Determining Acuity

…………………………………. ……………………………………….….


• Coding switched from acuity specific to acuity unspecified codes

Determining Acuity

The three-combination codes that include heart failure also require additional coding from the I50 series to specify the type and acuity of the failure…

https://www.aafp.org/fpm/2014/0300/p5.htmlHow to Document and Code for Hypertensive Diseases in ICD-10 -- FPMwww.aafp.org



Determining Acuity

IsitacuteHF?(clinician

assessment)

minrankforacuteHFcode

minrankforany HFcode CMS-definedHF DRG-definedHF

yes 1 1 1 0yes 2 1 1 1yes 4 1 1 1yes 5 1 1 0yes 6 1 1 1yes 7 1 1 0yes 2 2 0 0yes 2 2 0 0yes 2 2 0 0yes 2 2 0 0yes 2 2 0 0yes 2 2 0 0yes 2 2 0 0yes 3 3 0 0yes 3 3 0 0yes 3 3 0 0no 1 1 1 1no 1 1 1 0no 2 1 1 1no 2 1 1 1no 2 1 1 1no 2 1 1 1no 2 1 1 1no 2 1 1 0no 6 1 1 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 2 2 0 0no 3 3 0 0no 3 3 0 0no 3 3 0 0no 3 3 0 0no 3 3 0 0



• Broader analysis showed no clear predictor of clinician defined ‘acute HF’

Determining Acuity




• Current solution: offer multiple definitions of HF + remove ‘primary Dx is acute’ filter

Determining Acuity




• Current solution: offer multiple definitions of HF + remove ‘primary Dx is acute’ filter

Need to better align clinician + coding + quality assessment worlds!

Driving Impact With The Dashboard

0

20

40

60

80

HFrEF HFpEF EF unspec CS HF with PH

HF Type

NYM All

0.00

20.00

40.00

60.00

HF All HFrEF HFpEF EF unspec

CS HF with PH

Mortality

NYM All Benchmark

0

10

20

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CS HF with PH

LOS

NYM All

0.00

10.00

20.00

30.00


CS HF with PH

30 day HF readmission

NYM All Benchmark

• Go-live was March 2018

• Outcomes data presented in monthly meetings

• Driving documentation improvement & practice assessment across the hospitals


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High risk cohort


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High risk cohort

What can we do to prevent readmissions?


“We’ve come to depend upon the dashboard and particularly the ability itgives us to drill down to the individual patient level data. We have a multidisciplinaryteam that reviews the dashboard data – and we use the dashboard toidentify patients who fall out of the metrics. We then reviewthe chart to determine what could have been done moreeffectively. In addition, based upon our early findings through this process we haveinstituted a daily communication between our coding anddocumentation team and our CHF NP to determine if patients are beingcorrectly identified as having CHF. Prior to this practice we were finding many patientsbeing incorrectly labeled with CHF, and this was hurting our metrics.”

- David Slotwiner, MDDivision Chief of Cardiology,NewYork-Presbyterian Queens Hospital

Part of a Larger Cardiovascular Regionalization Effort

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Electrophysiology

Cath lab

Heart Failure

CT surgery

Vascular

Congestive Heart Failure Network

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Clinician-to-Clinician Brief Video Blog

- Identifying Cardiogenic Shock- Navigating Guideline Cards- How to Start Sacubitril/Valsartan- Etc

Website Committee: Carolyn Halik; Maria Karas, MD; Tony Mercando; MD; Beatriz Niavsch

Inpatient and OutpatientGuidelines

Website &Regional Support

Dashboard

TeleMedicine

Nursing Education

Transitions of Care


Planning Phase

Acting PhaseChecking PhaseDoing Phase

Applying Technology Advances to Standardization

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Heart Failure Guidelines

PerspectivesHub and Spoke

53Modify with Insert > Header & Footer

NewYork-Presbyterian 2018 Goals

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ü Standardize– Guideline creation, next steps

revisionü Regionalize- Sharing ideas, sharing patients,

working together

ü Engagement– Key to Success– Focus on helping patients

“Live Longer, Live Better”

Virtualize – To Do’s

q Cross Campus NEW EMR – Incorporation of standards during

creation of NYP EMR

q Remote Disease Management– Sharing Protocols – Cross-Campus

Initiatives– Para-telemedicine Pilot– ”Wearables” and ”Implantables”

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The Process Improvement Challenge

Clinician engagement

Goals of leadership

Physicians engaged primarily in clinical work don’t think this way

Physicians engaged primarily in clinical work and

given the right tools follow this

process

Thank You

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standardization of heart failure care through a cross-hospital … · 2018-10-08 · heart failure...

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