Mid-Atlantic States Chronic Heart Failure Program


Farzaneh Sabi, MD; Machelle Behzadi, MHA;
Betty Rice; Jessica Kane; Blair Van-Horn


Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Mid-Atlantic States

Background: Heart failure (HF) is a chronic condition affecting millions of people every year. During the course of this condition, heart function may deteriorate, especially in people with poor diet and exercise habits, other chronic conditions, and poor compliance with medications. Investments in the early diagnosis and treatment of heart failure, including support with medication adherence, improving diet and reducing sodium intake, as well as increasing daily physical activity, can improve the overall quality of life and decrease the morbidity and mortality rates associated with heart failure.
Methods: The HF Program focuses on outreach and support for members with HF who demonstrated signs of decompensation or progression of their chronic condition. The goal of the program is to have high-frequency outreach with members to support them in gaining the knowledge to manage their HF. In collaboration with the members’ primary care physician/cardiologist, the nurses work closely with the members to review their compliance with medication, diet, and exercise recommendations by their physicians. This is achieved by performance improvements and monitoring of medication titration and adherence, lifestyle management, nutrition counseling, and life care planning through a combination of in-person consultations, telephone appointments, and classroom education by program registered nurses.
Results: The Regional HF Program launched in March 2018, and approximately 900 members were enrolled in the program as of December 31, 2018. This represented 11% of all Kaiser Permanente Mid-Atlantic States members with the diagnosis of heart failure. Members enrolled in the program had a 65% reduction of urgent care/clinical decision unit (CDU) utilization, a 19% reduction in their Emergency Department utilization, and a 56% reduction in their hospital utilization. Forty-nine percent of members in this program also had diabetes, and 98% were up to date on their annual hemoglobin A1C measurements. Eighty-one percent of members in this program had documentation of life care planning discussions, and 17% had an advanced directive on file. One hundred seventeen members successfully graduated from this program through demonstration of improvements in their clinical conditions, demonstration of understanding and adherence to medication regimens, daily weight and blood pressure measurements, and sustained lifestyle changes to improve their overall health and outcomes.
Discussion: Intensive outreach programs focusing on medication adherence and understanding and changes in lifestyle including diet, exercise, and smoking cessation, led to improvements in overall health and reductions in avoidable Emergency Department and hospital visits for members with decompensating HF.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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