Treating more patients with heart failure outside the hospital

Steven Heatherly says too many patients with heart failure are being treated in the hospital.

Heatherly is the medical director of heart failure and pulmonary hypertension at Baptist Health System, which operates eight hospitals in Kentucky and a hospital in Indiana. Heatherly says many patients with heart failure can be treated on an outpatient basis at heart clinics, and with remote patient monitoring.

Baptist Health recently completed a trial program of remote patient monitoring of heart failure patients. The program was small - a group of 41 patients - but Heatherly found the results to be very encouraging.

Only one patient was readmitted to the hospital. Three patients died, but Heatherly said more patients survived and avoided hospitalization than expected, especially since the group consisted of high-risk patients in their 70s. After 90 days, more than 94% of the participants were still alive.

“It's a very small pilot, but had really amazing results,” Heatherly says.

Now, Heatherly says Baptist Health is expanding its remote patient monitoring of heart failure patients. In an interview with Chief Healthcare Executive®, Heatherly outlines the experience at Baptist Health, the need to shift more patients with heart failure to outpatient treatment, and the expansion of care outside the hospital.

(See part of our conversation with Steven Heatherly in this video. The story continues below.)

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Generating more appointments

Baptist Health launched the pilot program out of Louisville. Since then, the system has begun remote patient monitoring out of another heart clinic, with plans to expand to three other heart clinics this year.

The system partnered with Current Health, which provides technology for remote patient monitoring and hospital-at-home programs for a host of systems. With the program, patients wore devices to check vital signs and also weighed themselves regularly. Current Health is part of Best Buy Health, which has recently partnered with Atrium Health on a project to improve hospital-at-home programs.

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So far, the remote patient monitoring program is getting more people who are having problems, such as the accumulation of fluids, to go to the clinic for IV diuretic treatment. With the program, they are detecting patients with problems earlier.

“I think the biggest thing that happens is it generates clinic appointments,” Heatherly says. “It lets you know there's something not quite right about this patient's volume status, and then we bring them back into the clinic.”

The remote patient monitoring program also encouraged patients to follow their medication plan and make healthier choices, Heatherly says.

“We've had several patients tell us this because they knew we were watching. They would say things like, ‘I was tempted to go to get fast food today. But I knew that the scale is going to be up tomorrow, and I knew your nurse was calling. And so I just didn't do it,’” Heatherly says.

“So I do think there's an impact on how they live at home, when they know that we're actually looking at the vital signs and their weights,” he adds. “And that does make a difference.”

Even though the patients in their initial trial were older (the median age was 75), they had no difficulty using the monitoring devices. He said connectivity wasn’t an issue in Louisville, although it could become more of a challenge as the remote monitoring program rolls out into more rural communities.

Heatherly says the system needs to do more analysis to determine if the remote monitoring program is producing substantial savings. He says the program has prevented some people from making a return to the hospital, and hospitals can face penalties from Medicare for excessive readmissions.

“In my mind, it makes total sense that this would reduce costs,” he says.

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‘The mindset has to change’

For years, patients with heart failure, including those with too much fluid, have been directed to the emergency department and typically admitted for a few days.

That’s starting to change, as more people are being treated at heart clinics, but Heatherly says the change is occurring slowly.

“Unfortunately, we're still admitting a lot of those patients to the hospital,” Heatherly says.

Patients with heart failure don’t need to go to the hospital if they have normal blood pressure and normal oxygen levels, Heatherly says. They can be managed on an outpatient basis.

“I would say in the next five years, you should see significant outpatient care of heart failure exacerbations,” Heatherly says. “And certainly within a decade. It's just the mindset has to change. There's culture, there's a little bit of inertia in medicine.”

Heatherly is a proponent of health systems investing in heart clinics, which allow patients with heart failure to avoid admission to a hospital. But he says it requires a commitment.

“First, you've got to get your physicians, your nurse practitioners, your nurses, your medical system, it has to be up and running,” he says. “You've got to be sure that you sort of over-supply and overstaff the clinics when they first start, because … you never want an ER doctor, or primary care to call and you have to say, ‘I can't see that patient right now.’ That can never happen.”

“So I always say you're sort of paying a lot of extra people first, even though the volumes aren't there,” he says. “But you're doing that very intentionally because you want the clinic appointments open. And then you want to offer same day appointments.”

Heatherly says he’s a “big fan of heart failure clinics.” He says heart failure is a condition best managed in a disease-specific clinic.

“And we've shown that here repeatedly,” he says.

While some people with heart failure are going to end up in the hospital, or readmitted to the hospital after discharge, Heatherly says many admissions aren’t needed.

Heatherly says when he talks to other hospitals and health systems, he encourages people to “see every single heart failure admission as a failure. It should be a zero event. And if it's happening, you have to ask why.”

Heatherly stresses that he’s referring to patients with stable ventricular function, which make up the majority of heart failure patients.

“They're being admitted, and they come in this month, and the next month and the next month,” Heatherly explains. “That's what I think should not be happening.

“It's those preventable admissions that I'm talking about,” he adds. “Those are the ones that lead to frailty and malnourishment, disability, quality-of-life issues. Those are the ones we want to prevent. But I would like everyone to get in the mindset of saying, ‘This shouldn't happen. And what is happening here with this patient, why are they here?’”

Moving outside the hospital

With strong results in treating patients in heart clinics, and promising findings with remote patient monitoring, it’s clear that health systems are going to be delivering more care outside the hospital, Heatherly says.

He says he expressed that view when he took on his role as medical director of the heart failure program.

“It's been my prediction for the past few years that …. where we are going as a healthcare system is more and more sick patients being treated not in the hospital,” Heatherly says.

“I really think we will reach the day where really sick people are in the ER, getting surgery or admitted to the ICU or the hospital,” he says.

Many heart failure patients getting admitted to hospitals could be treated in a clinic setting or the home, he says.

“And I actually 100% believe that's where we're going in that direction,” he says.