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Heart Failure Disease Management (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, Linda Wick made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (1.9 MB). Plugin Software Help.

Slide 1

Heart Failure Disease Management : Essentia Health's Experience In Scale Up and Spread

Slide 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.

Slide 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 acquired health care system—Brainerd, MN.
  • In process of developing program in Fargo, ND.

Slide 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.

Slide 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.

Slide 6

Image: A boat in the water is shown.

Slide 7

Image: A breakwater is shown.

Page last reviewed October 2014
Internet Citation: Heart Failure Disease Management (Text Version). October 2014. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


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