Keeping Patients with Congestive Heart Failure Healthy and Out of the Hospital
In 1998, Carl Heltne, MD, was an interventional cardiologist and department chair at a hospital in Duluth, Minnesota, that later became part of Essentia Health. He enjoyed a busy schedule of procedures, appointments, on-call duty, and much more.
Heltne was bothered by the frequency that patients recently discharged from the hospital with a diagnosis of congestive heart failure (CHF) were being readmitted. Searching for a root cause, he judged that the problem was neither poor diagnoses nor poor treatment plans. Instead, the issue seemed to be inadequate post-discharge follow-up.
These patients and their families generally did not have a good grasp of CHF. Thus, they were limited in their ability to fully participate in their care. Furthermore, the effectiveness of CHF medications is sensitive to dose, which typically needs adjustments depending on how the patient responds. Perhaps simply due to the heavy demands on their time, neither the cardiologists nor the primary care physicians were getting the job done.
After studying the literature and learning about a few related endeavors around the country, Heltne decided to create a small team—two nurses and a nurse practitioner—who would look after CHF patients full-time. Some of his colleagues objected; they anticipated that the program would lose money. Heltne overcame their resistance by stating simply that it was the right thing to do. Their mission was to serve patients.
Many years after the program’s launch, an internal financial analysis showed that the program did not operate at a loss. It was more or less a breakeven proposition despite the reality that many of its services were not reimbursable. The reason, according to the analysis, was that CHF admissions were unprofitable under Medicare’s reimbursement schedule, and the program reduced those admissions. The program looked far better than breakeven under any of several value-based payment models.
By 2016, Heltne had retired but the program remained strong. Indeed, it had had grown to an average of roughly 2,800 patients on any given day. Eight nurse practitioners or physician assistants (NP/PAs) each managed a panel of 350 patients. The team also included the full-time equivalent of eight nurses.
A hospital is no place to educate a patient.
Indeed, few newly diagnosed CHF patients retain much of what they are told while hospitalized. Part of the problem is that “congestive heart failure” is a misleading name. It sounds grave or even fatal when in fact it simply indicates that the heart is pumping an inadequate volume of blood, which can lead to such symptoms as accumulation of fluids in the body or shortness of breath. CHF will indeed lead to death if untreated, but with proper medications CHF can be kept in check for years.
Timely and comprehensive follow-up after discharge is important so that patients and their families understand the importance of sodium restriction, medication adjustments, and responsiveness to changes in symptoms, including weight gain and shortness of breath. In absence of this continuing care, a readmission to the hospital can easily follow. In Heltne’s experience, return visits to the hospital can be devastating for patients and their families.
By 2016, the CHF program required little physician supervision. It was run day to day by program manager Denise Buxbuam. Prior to Buxbaum, Linda Wick had held the position for nearly 13 years, from 2001 through 2014, growing and refining the program until she was offered a new position with broader responsibilities at University of Minnesota Physicians.
The team generally scheduled the first appointment with patients just five to seven days after discharge. Patients typically were nervous so soon after their CHF diagnosis; almost all showed up for their appointments.
These initial visits were lengthy. They included a physical, a thorough review of medical history, and screens for depression, functional capacity and other health conditions, plus a great deal of education. The team also worked with the consulting cardiologist to assure that the correct diagnosis was made.
Perhaps the most crucial goal in the first appointment, however, was to ensure that patients felt they had a personal and trusting relationship with both the NP/PA and the nurse. The team wanted patients to be completely comfortable calling the clinic at any time. Wick elaborated:
After their first visit, patients knew that when they called, they’d get a callback from someone who knew them. It wasn’t some random phone nurse. This was someone they’d met, who’d met their family, who understood their condition, and who understood their living situation.
Indeed, the team came to view persuading patients to report any changes in symptoms as the key to the program’s overall success. Such reports often led to an adjustment in medications or additional coaching on behavior or diet. These adjustments could be crucial in avoiding readmissions.
Patients who felt a strong personal bond with the CHF clinicians were far more likely to engage with the CHF team than they were to wait and hope and possibly end up in the emergency room. For the most severe cases, the team also used technology to stay in touch. They sent patients home with a telescale that automatically transmitted the patient’s weight to the team and allowed patients to press buttons to answer a few questions about their symptoms each day.
To build trust, the clinicians engaged patients in conversations about what was most important to them. What activities did they most hope to remain engaged in? Playing with grandchildren? Walking to the end of the driveway to retrieve the newspaper? Also, the clinicians talked with patients about any real-life constraints that could get in the way of care, such as inability to pay for medications or buy healthy foods. These conversations also helped the clinicians gain insight into patients’ lives, enabling them to be more effective behavior coaches. Patients were most responsive to coaching that was directed towards goals that were meaningful to them and sensitive to any constraints that they faced.
The CHF team took one additional step to cement the relationship with patients. Not long after the first appointment, they phoned the patient just to check in and see how they were doing.
After the first appointment, the team’s top priority became ensuring that the CHF medications were adjusted to an optimal dose. Most patients needed some time to adapt to the new medications, so doses were ramped up slowly. It could take several visits and phone calls to establish a stable medication plan. (The effort certainly helped emphasize to patients the importance of taking the medications!)
Over the longer term, the staff addressed related medical challenges. Pain management (from, say, arthritis) could be challenging because of drugs that were incompatible with CHF medications. Additionally, the CHF population had a high incidence of untreated depression. Because alleviating depression can improve success with CHF care, the staff worked to identify depressed patients and get them treated. This often required a lengthy conversation (15–20 minutes rarely was adequate; 45 minutes often was) with patients, both to accept a diagnosis of depression and to consider medication for it.
The CHF team also worked to build a close relationship with palliative care/hospice providers and to ensure that patients were enrolled appropriately based on their wishes and goals. One of the challenges in this regard was that the progression of CHF was unpredictable and often marked by unexpected jumps in symptom severity. When a choice needed to be made, say, between hospice or a referral to a distant specialist in an academic medical center, the CHF clinicians gave patients the best information they could and then left the decision to patients. The team saw that in a hospice setting, CHF patients were often more able to manage their symptoms and receive the services they needed. In some cases, these patients improved and were discharged from hospice.
Beyond building trust with patients, the CHF team had to build trust with the other doctors who cared for them, particularly cardiologists and primary care physicians. Doing so required openly sharing information that the program acquired about patients and keeping doctors informed of any significant changes in medical condition.
Data also helped build trust. The team demonstrated that 90–95 percent of the patients in the program were on proper medications, compared to less than half nationally. Eventually, doctors acknowledged the success. They also saw that the program improved their lives at work. Wick explained:
Although there was some resistance, the docs learned that the patients in our program didn’t call after hours and they didn’t end up in the ER. So, suddenly the docs weren’t so consumed with CHF patients and they could do what they really wanted to do, which is take care of patients with more acute conditions, such as myocardial infarctions.
Recalling the program’s origins, Heltne reflects that he would not have thought to start such a program without a certain awareness of his limitations as an individual clinician. He remembers his residency as a formative experience in which he recognized that doing well by patients requires physicians to draw upon the best of those around them:
The mission that I committed myself to was to deliver the best care that I could to the patients, not to be an omnipotent physician.
Heltne has a vivid recollection of a patient that the program had served early on. The patient had multiple conditions that complicated her heart treatments and she had appeared to be near death. Heltne visited the patient multiple times each day while she was in the hospital, pouring heart and soul into the patient’s care in hopes that she’d make it out of the hospital. She did.
A few weeks later, he chanced to meet the patient while walking through the hospital with one of the CHF nurses. The patient gave the nurse a huge hug yet offered Heltne only a curt hello. The experience underscored just how much more than his own work was required to care for a CHF patient and redoubled his personal commitment to the program.
The program has evolved substantially from its early days. It was not clear at the outset, for example, how the team should be structured. Heltne did not know which health-care professionals would be best suited for the job, and he did not know how many clinicians would be needed to take care of a patient panel of a certain size. He moved forward with a hunch that the nurse practitioners he worked with every day would do quite well. He started small, just one nurse practitioner and two nurses, and then adjusted the program as he and the team learned from experience.
If Heltne has a disappointment, it is only that the program has not inspired more facilities around the country to do something similar. The inability to be reimbursed in an appropriate manner for many of the services the program provides appears to be the largest barrier. Heltne has tried to negotiate for reimbursement. He recalls:
There was a seminal event in my education with payers. We did a study to try to show that we should get a per diem. The numbers showed that we saved the payer over $1 million. Instead of offering a per diem, they gave me a plaque. They got $1 million and I got a plaque. That has just stuck with me forever.
Heltne laments a system in which it is so much easier to get reimbursement for new pills and devices than it is to be paid for low-tech interventions that deliver powerful results. Late in his career, as a chief medical officer at Essentia Health, he experienced similar frustrations with telemedicine programs that were of great benefit to patients in the rural setting. Nonetheless, Heltne remains upbeat.
Most victories in life are private victories. I had a great time building this program. It was meaningful, fun, and it was gratifying to see the positive impact on patients and their families.
He adds that it was a joy to experience the benefits of a team approach to the care of patients, a team where each person participates to the full extent of their training and licensure.
Heltne eventually won a concession from Medicare: a per-member, per-month payment for patients in the CHF program.