Heart Failure Disease Management (Text Version)

On September 19, 2011, Linda Wick made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (1.9 MB). Plugin Software Help.

Slide 1

Heart Failure Disease Management : Essentia Health's Experience In Scale Up and Spread

Slide 2

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.

Slide 3

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 acquired health care system—Brainerd, MN.
• In process of developing program in Fargo, ND.

Slide 4

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.

Slide 5

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.

Slide 6

Image: A boat in the water is shown.

Slide 7

Image: A breakwater is shown.