Heart failure (HF) is both progressive and chronic and affects more than 6 million American adults, according to the American Heart Association.1 A complicated condition, it is often accompanied by multiple comorbidities, such as chronic obstructive pulmonary disease and diabetes, and requires multidisciplinary teams to treat.
Despite difficulty in the treatment of HF, the Baylor Scott & White Health (BSWH) group, comprising multiple health centers and hospitals including Baylor University Medical Center and Scott & White Medical Center, is tackling the condition in a comprehensive approach.
“Our system recognizes the importance of heart failure in our patient population and chose it as the [condition] to focus the development and implementation of a system-wide disease management program,” Shelley Hall, MD, chief of transplant cardiology, mechanical circulatory support, and heart failure at Baylor University Medical Center, told MD Magazine®. “This means from diagnosis to death. This is an amazing feat to undertake because it involves every aspect of a health care system—outpatient offices, cardiology and primary care, hospitals, [emergency departments and emergency medical services], postdischarge facilities, and heart failure clinics.”
The program for HF is as extensive as the condition itself. It involves doctors, nurses, and other medical professionals from numerous specialties—cardiovascular surgery, hospitalists, palliative care providers, intensivists, and dietitians, among others, are all involved. It also features the latest technology and, of course, a complete team-based approach.
“We realize that heart failure [prevention] begins with identification of risk factors…before someone develops heart failure, and we go about educating both the community and physicians about early detection and prevention,” said Robert C. Scott, MD, PhD, FACC, medical director of advanced heart failure, mechanical circulatory support, and cardiac transplantation at the Scott & White Medical Center in Temple, Texas. “Through our system approach, we have measures in place for heart failure patients at all stages of care— prevention, outpatient clinics, in-hospital care, advanced therapies, post hospital care and recovery, and palliative care measures.”
The program began in 2015, in hopes of taking comprehensive disease management to a new level. Recognizing that its own patient population had a high incidence of HF, the hospital sought to develop a program that could aid the most patients while simultaneously taking on a complicated and hard-to-treat condition.
“Heart failure came to the forefront of cardiology concern when the heart failure readmissions were being penalized by CMS,” Hall said. “Since then, hospitals and medical communities have been looking at better ways to care for these patients. Some ideas have worked; some have not—it is a massive problem with many facets and thus has no easy fix.”
One of the biggest issues in HF is a lack of physician and patient knowledge about the condition. Patients who are at risk for HF, known as stage A HF, often don’t understand the risk factors that contribute to the condition, and the doctors who see the largest number of patients with HF—internists and family practice doctors—often have the least amount of time and resources to treat or screen these patients.
While research into stage A HF is considered nearly impossible because it requires such enormous trials, such as the Framingham Heart Study, according to Hall, the program has focused on educating patients and notifying physicians as early as possible about at-risk patients.
“We have some amazing technologies and therapies, but the best treatment, again, truly is prevention,” Scott said. “We have extensive efforts in educating the community because we believe that a patient’s knowledge of heart failure empowers them, and they become more confident and comfortable.”
Patient education in the program includes videos to let patients know more about the morbidity and mortality associated with HF and all that goes into managing and preventing it. Often, patients are unaware of the nutrition and salt restriction needed in their diets or the impact—negative or positive—that smoking, exercise, weight loss, and glucose control can have on impending HF.
“We have created universal, system-wide education materials for patients so that no matter where they go within BSWH, they will get the same education,” Hall said. “Physicians are so overburdened now, it is almost impossible to keep up with all the demands. So as part of our total disease management process, we have also developed triggers in the electronic health records [EHRs] for identifying at-risk patients.”
The EHR triggers ensure that patients get the guideline-directed therapies as soon as they require them and allow for better communication among the multiple health care professionals who see patients with HF. This is increasingly important considering that a team-based approach, similar to the one taken by BSWH, is becoming the standard for HF treatment.
“[Our] standardized office [EHR] triggers to make sure patients are getting guideline-appropriate interventions—whether those are medicines, an [implantable cardioverter defibrillator], referrals or advanced care, surgical interventions, or advanced care planning,” Hall said. “I don’t know of any system that has tackled comprehensive disease management in this way.”
In addition to the EHR triggers for notification, the collaborative care effort helps make the detection of at-risk patients much easier. It also alleviates some of the burden on the patients and physicians by putting everything—and everyone—in 1 place. This allows patients to avoid making multiple trips to multiple locations and eases the line of communication between team members.
“This heart failure team comprises board-certified advanced heart failure and transplant cardiologists, cardiothoracic surgeons, HF nurses and nurse practitioners and physician assistants, social workers and dietitians, cardiac exercise physiologists and rehab experts, financial coordinators, chaplains and religious personnel, pharmacists, psychologists and therapists, and palliative care physicians and nurses,” Scott said. “Patients can be seen by multiple specialists during 1 trip to our institution. Likewise, all testing, including advanced testing, and invasive and noninvasive procedures are all done here in 1 location. This makes it more conducive for family and friends to accompany the patient to their appointments.”
Although the program for HF is extensive and is taking steps to lead the way in HF treatment, the HF clinics within BSWH’s group are top-of-the-line and are adapting and treating patients every single day, according to Hall. The group has 13 advanced HF clinics spread throughout the state, all of which service the patients who have progressed the furthest into HF and have the highest rates of mortality.
Each clinic also offers extensive educational materials and opportunities for patients with HF, according to Scott, allowing for close and personal relationships to be developed, which in turn helps the clinic’s care of the patients. Additionally, the clinics offer educational seminars to the public that teach potential patients about prevention and the risks of HF.
“Our heart failure clinics are amazing,” Hall said. “They care for the sickest heart failure patients in our system and have the lowest readmit rates and highest patient satisfaction. That is unbeatable considering the very complex, high-mortality-rate patients they care for every day.”
Benjamin EJ, Blaha MJ, Chiuve SE, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Correction to: Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017; 135(10):146-603. doi: 10.1161/CIR.0000000000000485