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Heart Failure Disease Management

Heart Failure Disease Management. ESSENTIA HEALTH ’ S EXPERIENCE IN SCALE UP AND SPREAD. MODEL OF CARE. MULTIDISCIPLINARY DISEASE MANAGEMENT PROGRAM PATIENTS MANAGED BY NURSE PRACTITIONERS/PHYSICIAN ASSISTANTS IN COLLABORATION WITH CARDIOLOGIST

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Heart Failure Disease Management

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  1. Heart Failure Disease Management ESSENTIA HEALTH’S EXPERIENCE IN SCALE UP AND SPREAD

  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

  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 AQUIRED HEALTH CARE SYSTEM – BRAINERD, MN • IN PROCESS OF DEVELOPING PROGRAM IN FARGO, ND

  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

  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

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