# Presentation: 389010

## Minneapolis VAMC HF Telehealth Clinic

**Clinic members:**
-  Director: Inder Anand, MD, PhD
-  NPs: Connie Jaenicke, Judy Wagner, Robin Smith RN: Sharon Ericksen (FTE=3.0)
**Patients:**
-  65-70 patients with multiple hospitalizations managed on daily telehealth equipment;
-  210 telephone patients;
-  218 discharged patients since clinic initiation 6/1/05
**What we do:**
-  	Medication up-titration to standard of care, risk factor control over the phone with 	lab work 				performed locally or remotely, most-all of cardiology care
-  	Closely manage fluid status (outpatient options, IV lasix on obs, ultrafiltration)
-  	Case manage,  provider manage, and/or screen for other medical co-morbidities
-  	Monthly patient class, multiple presentations to staff, template, protocol work
-  	Consult with inpatient team when patient admitted with ADHF for discharge planing

## Minneapolis VAMC HF Telehealth Clinic

_**High-risk**_
**Intensively managed by CDM Heart Failure Staff and may be referred back to Primary Care after stabilization.**
- Class III/IV HF
- Heart failure hospitalization in the last 		6 months
- Acute MI
- AS; valve <1.0cm2
- Moderate to Severe MR or TR
- Cor pulmonale
- Creatinine >2.0; requiring titration of 		medication
- Systolic BP >180 or <100
- New onset atrial fibrillation
- Clinically unstable; requiring phone 			calls >2x/week or having frequent 				changes in health status
- New diagnosis of heart failure

- 1)	Patients with or without LV dysfunction and/or diagnosis of heart failure are 		triaged by chart review and/or consult and categorized as high, 	medium, or low 	risk. Echos and PFTs ordered as indicated.
- 2)	Patients are identified via echo as asymptomatic LV dysfunction

_**Low risk**_
**Managed independently by primary care; although PCP can send request for initial consult only if needed.**
- Absence of high or medium-	risk criteria, requires 					titration of medication
- Absence of high or medium-	risk criteria, on heart failure 	standard of care

**Telemedicine consult from outside facility****_x0003__x0016_**

_**Medium-risk**_
**Titration performed by Heart Failure Staff.  **
- Absence of high-risk criteria
- Creatinine 1.4-2.0; requiring 		titration of medication
- Current or history of 					electrolyte imbalance (ie 			hyperkalemia).
- Asymptomatic LV dysfunction

**Refer to next page**

## Minneapolis VAMC HF Telehealth Clinic

- Multiple hospitalizations  or 1 	admission with at least 1 			UC/ER visits (either for CHF 		or ARF/dehydration); or 			requires daily monitoring/has 		failed telephone monitoring as 	clinically determined by heart 		failure staff
- Able to use equipment 				(cognitively, functionally, 			motivated, +family support for 	initial set-up and trouble-			shooting if patient unable to 		do, patient or active family 			member able to give accurate 		assessment of heart failure, 			room for equipment in home, 		analog phone line).
- Will include self-management 		and CHF group classes

**Do not meet above criteria for Viterion equipment, but meets criteria for telephone management**
- Able to give accurate assessment of heart failure 		symptoms, stable heart failure, capable of using 		scale and blood pressure cuff, intended short-term 	nursing home placement, patient agreeable to being 	followed on phone.
-  	If patient meets criteria for Viterion 100 equipment 	with the exception of analog phone line, room for 	equipment, or functional ability (that can be 				overcome with using phone follow-up), may be 		placed on telephone management as well.
-  	Will include self-management and CHF group 			classes

**High risk**

**Do not meet criteria for Viterion equipment or telephone follow-up**
**→****In-clinic visits**
- Will include self-			management and CHF 	group classes 				(involving NPs, RNs, 		dietician, pharmacist, 		exercise therapist)

**Criteria for discharge back to primary care:**
- Optimally titrated and stable heart failure for 	12 months. Weaned to telephone or in-clinic 	visits as indicated.
- Some patients may need to be in a heart 		failure clinic indefinitely or referred to 		hospice.

## Minneapolis VAMC HF Telehealth ClinicIndications for Referral  back to Heart Failure Staff.

- Refer to high-risk algorithm; will be intensively followed by CDM Heart Failure Staff.

**Indication for Referral back to CDM Heart Failure Staff****: **
- Patients being followed in or 	co-managed with primary 		care who meet high-risk 		criteria or who the Primary 	Care Team identifies as 		needing more intensive 		management.
- Patients being followed in 		the General Heart Failure 		Clinic who have been 		hospitalized or have frequent 	ER visits, and are telehealth 	candidates.

**Indication for Referral from HF Telehealth Clinic to General HF Clinic:**
- Patients identified as 			requiring indefinite, in-		clinic follow-up by a HF 	Clinic as determined by 		CDM Heart Failure Staff.

- CDM Heart Failure Staff will send consult to Heart Failure Clinic.

***Note:**** Patients who have a current or past history of medication or visit non-compliance will be followed closely by clinic staff for 6 weeks. If patient does not utilize the telehealth equipment, clinic staff are unable to reach patient by phone, or the patient **“no**-shows**”** twice, they will be discharged back to primary care. A notification will be sent to the primary care provider via e-mail, consult reply, or letter. Other exclusion criteria are those with cognitive deficits who are unable to make safe medication adjustments, hospice patients, and those on dialysis.*

## Cost Savings (Data Support System) 

- 201 Phone and Telemonitoring pts 7/5/06 to 4/18/07
- 73% reduction in total hospital admissions
- 77% reduction in inpatient LOS (days).
- Cost savings comparing before and after enrollment: $3,299,575
- 101 high-risk daily tele-health patients from June, 2006 through November 2007 (see Figure 1).
- Length of stay was also reduced.
- Cost savings were calculated independently by the Decision Support System staff and demonstrated a $602,333 savings, including inpatient, outpatient,  salary and all tele-health equipment costs.

## Hospitalization rates pre-and post-enrollment.

## IV Diuresis Cost Savings

- 29 patients eligible for admission 5/2/06 to 7/10/08 were treated 63 occasions on the outpatient observation unit overnight by HF Tele-health staff
-  	53 for fluid overload refractory to outpatient diuretics
-  	5 for dehydration and over diuresis at home
-  	1 anemic requiring blood transfusion
-  	4 for hypokalemia
-  	54/63 (86 %) were discharged to home successfully
-  	9/63 (14 %) were admitted
-  	54 admissions saved; cost savings of $ 432,000

## Next Steps

-  	Increased integration of ultrafiltration in the tele-health 	program
-  	Practical 3-step approach to transitioning patients to 		palliative care