Essentia sees success with pioneering heart programBill Hill stands on a scale in a bedroom of his rural Cloquet home. A voice asks him a series of questions: Has he been short of breath? Has he noticed swelling in his feet?
By: John Lundy, Duluth News Tribune
Bill Hill stands on a scale in a bedroom of his rural Cloquet home. A voice asks him a series of questions: Has he been short of breath? Has he noticed swelling in his feet?
At Essentia Health St. Mary’s Medical Center, a computer program will call a nurse’s attention to any reasons for concern, such as a sudden weight gain, and a nurse will take action immediately.
It’s one tool in Essentia Health’s heart failure program, which has cut the readmission rate for patients with congestive heart failure to 7 percent — compared with the national average of 40 percent. That’s the percentage of patients readmitted within 60 days after being discharged. It’s a program that’s getting widespread attention, especially now that hospitals face a reduction of Medicare reimbursement for excessive readmissions. The penalties don’t begin to take effect until 2013, but they’ll be based on outcomes from federal fiscal year 2012.
The cost of hospital readmissions is breathtaking: A 2009 study in the New England Journal of Medicine based on 2003-04 data concluded that Medicare pays about $17.4 billion a year for unplanned readmissions.
Congestive heart failure is an important piece in the puzzle, because it’s the No. 1 reason for hospital admissions for people older than 65, said Dr. Carl Heltne, Essentia’s chief medical officer.
Now that Medicare reimbursements are on the line, Essentia’s successful heart failure program is drawing interest. Linda Wick, a nurse practitioner who manages the program, said she gets at least three calls a week from hospitals wanting to learn the secret.
‘I knew we could do better’
When Essentia started the program in 1998 at what was then SMDC, cost savings wasn’t the goal.
“We looked at this patient population and said there’s got to be a better way to take care of these people,” said Heltne, who then was physician leader of the cardiac unit. “There’s just got to be. And we looked at it from the perspective of care, not from the perspective of cost. … From a readmission standpoint, which to me is kind of a misery index, we were not where we should be. I knew we could do better.”
Ironically, though, succeeding in keeping patients out of the hospital wasn’t rewarding financially.
“Every time somebody hit the hospital with heart failure, everybody got paid for taking care of that patient,” Wick said.
Added Heltne: “When we put this program in place, this decreased our revenue for care of our patients.”
Keeping heart-failure patients out of the hospital takes a three-fold approach, Heltne said: the right diagnosis, evidence-based medicine and monitoring the patient.
The Telescale is part of that monitoring. Only 200 of the highest-risk patients among the 1,400 in the program have them, Wick said. Among those patients, the readmission rate is 1 percent to 2 percent.
Involving the family
But all of the patients, whether they have a Telescale or not, are seen at least four times a year. The first, two-hour appointment normally takes place within five days after the patient leaves the hospital. In addition, patients are urged to call the heart-failure program any time they have a concern.
“We try to encourage the family to be a part of that so that their family is hearing the same message,” Wick said. “Because oftentimes elderly people don’t want to be a bother. And I tell them it’s much more of a bother to me if you end up in the ER than if you come to my office.”
In addition to Duluth, Essentia has its heart-failure program in Virginia and Brainerd, and a shared program in Spooner and Hayward. It soon will have programs in Deer River and in Fargo, N.D., Wick said.
But fewer than half of eligible patients are in the heart failure program, Wick said. That’s why the overall readmission rate for Essentia Health St. Mary’s is 21 percent, not the 7 percent that’s reported for those in the program.
Wick cites a couple of reasons why patients aren’t enrolled. Patients might not want additional appointments, particularly if they live a relatively long distance from a site, such as in Moose Lake or Grand Marais. And not all physicians embrace the program.
“I had a physician say to me, ‘I don’t know why you see this patient four times a year. They haven’t been in the hospital for five years,’ ” Wick related, a touch of frustration in her voice. “Well, maybe that’s why they haven’t been in the hospital for five years, because we see them four times a year.”
Wick talks about the program’s “sexy devices,” such as the Telescale and the left ventricular assist device — LVAD. The latter was developed within the past five years as an “artificial heart, basically,” she said. Hill is one of four Essentia patients with an LVAD. A drive line to the device is attached above his waist. Soon, LVADs will be entirely implantable.
Hill has been enrolled in the heart-failure program since 2006 and has used a Telescale ever since, he said. But it was the LVAD, implanted at Fairview University Medical Center on July 1, 2009, that really changed his life.
“After this LVAD, I’ve got quality of life back,” Hill said. “I can’t do a lot, but I can do things.”
Added his wife, Vivian Hill: “Before he got the LVAD, we’d have to drive him up to the front door, and he’d have to stop halfway up the stairs to catch his breath.”
Bill Hill, who goes by the nickname “Hillbilly,” remembers being able to do little else than sit in a chair during the day. Now he takes trails on a four-wheeler and mows the lawn with a riding mower.
The heart-failure program made it possible, Wick said.
“Without our heart-failure program and without our connections to those LVAD centers, that wouldn’t be an option for us,” she said.
Use of the Telescales dates to the program’s beginning, in 1998. A study in the early 2000s by Blue Cross Blue Shield of 29 Essentia patients compared their hospital visits during the six months before and six months after using Telescales. The savings: $1.25 million.
“They broke it down by inpatient visits, outpatient visits, ER visits, pharmacy, lab, other testing,” Wick said. “Everything was almost exactly the same except inpatient and ER. And ER is expensive. And hospitalization is more expensive. So you keep people out of the hospital, you save the system money.”
But the program’s success isn’t ultimately about the devices, Wick said.
“The magic bullet is we’re a team with our patients,” she said. “There isn’t one device. There isn’t one protocol. In a system that has been so geared toward sexy devices — we love sexy devices — there’s nothing sexy about this. It’s having a relationship with your patient and being available for them and helping them manage their disease.”
Hill has his blood pressure and weight checked every morning, and then answers the questions, pressing “yes” or “no” on a device that’s about the size of a telephone answering machine. He has a checkup with Wick every three months. He occasionally gets a call from a nurse if his weight or blood pressure are out of the normal range.
What’s it like knowing someone in Duluth is keeping tabs on his health stats?
“It makes me feel good,” Hill said. “I know somebody’s watching me. So if I miss something, they’re there. I appreciate those people. They’ve done me a lot of good.”