Heart Failure Disease Management (Text Version)
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.
- 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.
- 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.
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.
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.
- 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.
Image: A boat in the water is shown.
Image: A breakwater is shown.