Dan West, Area Sales Director November 2012

1. Dan West, Area Sales Director November 2012

2. Objectives for this presentation: The BAYADA Way Why are we talking about heart failure? Facts about heart failure Definition of heart failure Causes, symptoms, diagnosis and treatment BAYADA services and painting the clinical picture Who are we talking to about heart failure? Using the Six Step Sales Process Marketing materials

3. Sales strategy and objectives are grounded inThe BAYADA Way

4. Why are we talking about heart failure? • October 2012, 2217 hospitals incurred a penalty for excessive 30 day readmissions related to heart failure, myocardial infarction and pneumonia. • October 2013 those penalties could double to a maximum of 2% of their Medicare revenue if they don’t improve. • October 2014 those penalties could double again to a maximum of 3% of their Medicare revenue if they don’t improve.

5. Heart Failure Partnerships Many hospitals have a heart failure program in place or they are working on one right now to prevent 30 day re-hospitalizations! BAYADA Heart Failure Partnerships: Cooper Hospital in NJ Upper Chesapeake Medical Center in MD

6. Heart Failure Statistics from the CDC CHF patients make up 12-15 million doctor’s office visits each year and 6.5 million hospital days a year. 5.8 million people in the US have heart failure. About 670,000 people are diagnosed with it each year.  20% of HF patients die within 1 year from diagnosis. In 2010, HF cost the US $39.2 billion. This includes the cost of health care services, medications, and lost productivity.

7. What is Heart Failure? Heart Failure: A chronic cardiac conditionthat can develop suddenly. The heart can no longer pump blood to the rest of the body appropriately because the left ventricle becomes either too stiff or too weak to pump.

8. Causes of Heart Failure #1 cause of heart failure: CAD or Coronary Artery Disease: The narrowing of the small blood vessels in the heart that restrict blood flow. Cardiomyopathy – Any disease of the heart muscle, leading to decreased function to the left ventricle such as: Congenital heart disease and abnormal arrhythmias Hypertension Heart attack Heart valve issues Emphysema and other diseases Over active or under active thyroid Severe anemia

9. Symptoms of Heart Failure • Fatigue, weakness, faintness • Loss of appetite • Fluid retention, weight gain, swollen ankles and feet • Shortness of breath when lying down or active • Coughing and congestion • Need to urinate during the night due to diuretic use late in the day. • Irregular heartbeat

10. Diagnosing Heart Failure AnEchocardiogram (Echo) measures how well the heart pumps (ejects) blood in the heart. A normal EF or Ejection Fraction is 50% or better and most people with HF have an EF of 40% or less. New York Heart Association Heart Failure Classification: NYHA- I (None to Mild) NYHA-II (Mild) NYHA III (Moderate) NYHA IV (Severe)

11. Treatment Goals for Heart Failure Relieve symptoms and improve the patient’s quality of life Slow the progression of the disease Reduce ER visits and avoidable hospital admissions Improve life expectancy

12. Heart Failure Treatments Early diagnosis and treatment can improve quality of life and life expectancy for people who have heart failure. Lifestyle Modification Medication Surgical Intervention

13. Lifestyle Changes for HF Patients Low sodium and low fat intake No smoking and limit alcohol Regular exercise after the patient is stable Weigh yourself daily and report any weight gain to your physician No caffeine Routine check ups

14. Heart Failure Medications ACE inhibitors - Angiotensin-converting enzyme inhibitors Beta Blockers ARB - Angiotensin II receptor blockers Diuretics Statins Calcium Channel Blockers Digitalis Glycosides or Digoxin

15. Heart Failure Surgical Interventions CABG- Coronary Artery Bypass Graft improves blood flow to the heart Pacemaker - A small device that's placed in the chest or abdomen to help control abnormal heart rhythms LVAD - The left ventricular assist device is a kind of mechanical heart. It's placed inside a person's chest, where it helps the heart pump oxygen-rich blood throughout the body. Valve repair, heart transplant and other surgical procedures

16. BAYADA Services for Heart Failure Patients Nursing: Monitor disease, respiratory status and exacerbations Medication Management Monitor vital signs Disease self-management education smoking cessation Education on weight fluctuations Nutritional education (use a dietician if available)

17. BAYADA Services for Heart Failure Patients Physical Therapy: Teach strengthening In home exercise program Ambulation and balance techniques Evaluate posture and positioning Teaching home safety Endurance training

18. BAYADA Services for Heart Failure Patients Occupational Therapy: Activities of daily living Energy conservation techniques DME instruction Medical Social Worker (MSW): Assistance in obtaining medications Access to community resources and family support Short term counseling

19. Heart Failure Zone Tool

20. Paint the Picture of a Patient for Services • HF patient on multiple meds with recent med change. • HF patient with increased heart rate or palpitations. • HF patient having difficulty breathing (dyspnea) with a persistent cough or wheeze. • HF patient with difficult breathing at rest or while sleeping that may come on suddenly or wake them up requiring them to elevate their torso. • HF patient with recent edema (swelling of legs or ankles) that causes their patient’s shoes to feel tight.

21. Paint the Picture of a Patient for Services HF patient complaining of always being tired or feeling anxious and restless. Patient with a recent HF exacerbation that required a hospitalization or ER visit. HF patient that could benefit from lifestyle modification: in home exercise program, smoking cessation, and nutritional education. HF patient with lack of appetite or feeling of nausea, fullness or sick to the stomach. HF patient that may have fallen due to a medication side effect or from tiredness and fatigue.

22. Who are we talking to about Heart Failure? Hospitals: Discharge planners, Case Managers, Social workers, RNs, Rehab Dept, Dietitian, Hospitalists, Executives Skilled Nursing Facilities: Social workers, DON, Rehab Director, Dietitian, Admissions Directors, Administrators, Medical Directors Assisted Living Facilities: Wellness RN, Admissions Director, Executive Director, Medical Directors Physicians and their staff: Doctors (Cardiologists, IM, FP, Geriatrics and Medical Directors), NPs, PAs, RNs, MAs

23. Discovery Questions Heart Failure Tell me about your most difficult HF patient and what are your challenges with managing them? Do you have any HF patients that frequent the ER, but don’t get admitted? During the summer heat do you worry about you HF patients and what do you do for them? Have you added or changed medication to any of your HF patients and are worried about their med management?

24. Discovery Questions Heart Failure What do you do for your HF patients that have put on 5 lbs. in a week? Do you have a plan for your HF patients when their cough has become worse? Have you had a HF patient fall at home and what did you do for them? Do you have any HF patients in your hospital/facility know that have been frequent flyers? Would you be interested in hearing how Bayada can help keep that patient from being readmitted to the hospital again?

25. Framing HF Statements Samples: “So if I’m hearing you correctly, you have HF patients that you worry about because they are constantly calling the office and they also frequent the ER for exacerbations?” “It sounds like these patients do not have an adequate support system at home and could benefit from some medication management, disease education and lifestyle modification, is that correct?” “So it sounds like heart failure patients are typically the frequent flyers in your facility and you are looking for some new ideas to help keep them from being readmitted to the hospital, is that correct?

26. Heart Failure Envision Statement Sample: “BAYADA wants to help keep your HF patients safe at home and prevent them from going to the ER and keep them from being readmitted. For your most difficult HF patients that you are worried about, Bayada can: Monitor their vitals during an exacerbation Manage their medications Provide disease education to the patient and family Provide a physical therapist to prevent deconditioning and prevent falls And we can also bring in a MSW to help with care giver burnout.”

27. Heart Failure -Commitment Samples: “Can you think of one of your most difficult HF patients that could benefit from BAYADA services and would you mind having someone call them right now while I wait? Let them know that BAYADA can send a nurse out to see them tomorrow and there is no co-pay with Medicare, so their will be no cost to the patient.” “Can we take care of your most challenging frequent flyer heart failure patient for a trial using our zone tool and we will report back to you every week with that patients progress?”

28. Heart Failure Flyer sales piece here Marketing Flyer is available on the Web Store and can be customized. 12-2319 FLY - Heart Failure

29. Prep for Selling Heart Failure Order your sales pieces Read your patient profile and carry it with you www.webmd.com www.kaiserhealthnews.org 5. Practice, Practice, Practice

30. Heart Failure Questions?

31. Heart Failure Thank You! dwest@bayada.com