# Presentation: 365294

## Re-Inventing the HF Program at Tucson VA

- Elizabeth Juneman, MD & Elaine Charteris, NP
- Heart Failure Program
- Southern Arizona VA Health Care System
- University of Arizona, Tucson

**Notes:**
Re-Inventing the HF Program at Tucson VA
Elizabeth Juneman, MD & Elaine Charteris, NP
Heart Failure Program
Southern Arizona VA Health Care System
University of Arizona, Tucson

## Background

- Southern Arizona VA Health Care System
- Referral area for all Arizona, part of New Mexico & western Texas
- University of Arizona & Sarver Heart Center
- Dr. Steven Goldman
- Prior SAVAHCS HF program
- Part-time near-retired cardiologist
- Part-time HF NP

**Notes:**
Background

Southern Arizona VA Health Care System
Referral area for all Arizona, part of New Mexico & western Texas
University of Arizona & Sarver Heart Center
Dr. Steven Goldman
Prior SAVAHCS HF program
Part-time near-retired cardiologist
Part-time HF NP

## Background

- HF Performance Measures
- New academic cardiologist
- Basic science research in HF
- New dedicated HF NP

- RE-INVENT HF PROGRAM

**Notes:**
Background

HF Performance Measures
New academic cardiologist 
Basic science research in HF
New dedicated HF NP

RE-INVENT HF PROGRAM

## Background

- Consistently w/in 95% benchmark for EPRP for HF
- Despite that, SAVAHCS HF Program:
- Lack of focus
- 30-day post-hospitalization follow-up
- Transplant patients
- Device referral and follow-up

**Notes:**
Background

Consistently w/in 95% benchmark for EPRP for HF
Despite that, SAVAHCS HF Program:
Lack of focus
30-day post-hospitalization follow-up
Transplant patients
Device referral and follow-up

## Goals

- Focus on AHA HF Stage C
- Transplant care coordination
- Conjunction with U of A
- Device management
- Enrollment in clinical trials

**Notes:**
Goals

Focus on AHA HF Stage C
Transplant care coordination
Conjunction with U of A
Device management
Enrollment in clinical trials

## Outline

- Outpatient clinics
- Inpatient care
- Device / remote monitoring
- Transplant
- Clinical trials
- Outstanding Issues

**Notes:**
Outline

Outpatient clinics
Inpatient care
Device / remote monitoring
Transplant
Clinical trials
Outstanding Issues

## Documentation First !

- New HF Templates
- Medications by class & titration scale
- Revascularization / viability
- ICD / Remote monitoring
- CHF study enrollment potential
- Vaccines / smoking / weight / afib
- Document education done
- Information for referring MD

- Can be sent to you if requested ...

**Notes:**
Documentation First !

New HF Templates
Medications by class & titration scale
Revascularization / viability
ICD / Remote monitoring
CHF study enrollment potential
Vaccines / smoking / weight / afib
Document education done
Information for referring MD

## Outpatient Clinics

- All consults for HF screened by NP
- Post-hospitalization f/u captured by NP
- 4 half-day clinics (MD & NP)
- 1 urgent slot each clinic
*Active or decompensated* HF patients
*Stable* ... returned to PCP or general cardiology clinic

**Notes:**
Outpatient Clinics
All consults for HF screened by NP
Post-hospitalization f/u captured by NP 
4 half-day clinics (MD & NP)
1 urgent slot each clinic
Active or decompensated HF patients
Stable ... returned to PCP or general cardiology clinic

## Outpatient Clinics

- Patient education
- Individually & with hand-outs
- Group clinics ... TBA
- 8-10 patients
- 30 minutes
- Cardiology Fellow
- Social service required for fellowship

**Notes:**
Outpatient Clinics

Patient education
Individually & with hand-outs
Group clinics ... TBA
8-10 patients
30 minutes
Cardiology Fellow
Social service required for fellowship

## Multi-Disciplinary HF Clinic

- Staff
- Cardiologist
- HF fellow
- HF NP
- Pacemaker RN
- Sonographer
- Pharmacist
- +/- Electrophysiologist

- 1 half day clinic / wk
- “Round-Robin”
- Device check
- Echo guided AV Opt
- Med reconciliation
- Fluid assessment
- Education materials

- START DATE SEPT 2008 ... 1st in Tucson

**Notes:**
Multi-Disciplinary HF Clinic

Staff
Cardiologist
HF fellow
HF NP
Pacemaker RN
Sonographer
Pharmacist
+/- Electrophysiologist

1 half day clinic / wk
“Round-Robin”
Device check
Echo guided AV Opt
Med reconciliation
Fluid assessment
Education materials

START DATE SEPT 2008 ... 1st in Tucson

## Inpatient Care

- Cardiology Fellow on CCU
- Occasional dedicated HF fellow
- Transitional end-stage devices not available at our VA
- LVAD, RVAD, artificial hearts ... U of A
- Discharge RN protocol
- Not under cardiology jurisdiction
- Area of potential growth if more FTE

**Notes:**
Inpatient Care

Cardiology Fellow on CCU
Occasional dedicated HF fellow
Transitional end-stage devices not available at our VA
LVAD, RVAD, artificial hearts ... U of A
Discharge RN protocol
Not under cardiology jurisdiction
Area of potential growth if more FTE

## Devices & Remote Monitoring

- Area of interest
- New electrophysiologist
- Approx ~150 patients with active devices with potential for remote monitoring
- Cooperation & coordination with industry
- Data management ... BIG ISSUE

**Notes:**
Devices & Remote Monitoring

Area of interest
New electrophysiologist
Approx ~150 patients with active devices with potential for remote monitoring
Cooperation & coordination with industry
Data management ... BIG ISSUE

## Devices & Remote Monitoring

- Pacer RN & HF NP
- Goal to follow-remote data 1 day per week
- VT episodes
- ATP, tachyarrhythmias
- Fluid management, HRV, activity
- % Bi-V pacing
- Multi-disciplinary HF Clinic

**Notes:**
Devices & Remote Monitoring

Pacer RN & HF NP
Goal to follow-remote data 1 day per week
VT episodes	
ATP, tachyarrhythmias
Fluid management, HRV, activity
% Bi-V pacing
Multi-disciplinary HF Clinic

## Transplant

- ~30 patients
- ~20 patients followed University of Arizona Cardiac Transplant Team
- 6 coordinators
- Re-establish working relationship
- Annual work-ups & biopsies
- Immunosuppression

**Notes:**
Transplant

~30 patients
~20 patients followed University of Arizona Cardiac Transplant Team
6 coordinators
Re-establish working relationship
Annual work-ups & biopsies
Immunosuppression

## Clinical Trials

- At any time, 5-10 active enrolling HF trials
- VA sponsored & industry
- Ask *all* HF patients if they are interested  forward to research coordinator
- Prompt in HF template
- Research coordinator rounds with CCU team daily & in fellows clinic
- Increased study enrollment

**Notes:**
Clinical Trials

At any time, 5-10 active enrolling HF trials
VA sponsored & industry
Ask all HF patients if they are interested  forward to research coordinator
Prompt in HF template
Research coordinator rounds with CCU team daily & in fellows clinic
Increased study enrollment

## Definition of Success

- Benchmarks
- 30-day re-admission rate
- Measurement of LVEF ... we do this well
- Post-hospitalization follow-up
- High risk in 48 hrs
- Personal
- Remote monitoring
- Multi-disciplinary HF Clinic

**Notes:**
Definition of Success

Benchmarks
30-day re-admission rate
Measurement of LVEF ... we do this well
Post-hospitalization follow-up
High risk in 48 hrs
Personal
Remote monitoring
Multi-disciplinary HF Clinic

## Outstanding Issues

- Dedicated pharmacist
- Separate careline TELEHEALTH
- No integration with cardiology
- Some patients live in Mexico
- No ability for remote monitoring
- HF Admission Orders
- Work-load capture of remote monitoring

**Notes:**
Outstanding Issues

Dedicated pharmacist
Separate careline TELEHEALTH
No integration with cardiology
Some patients live in Mexico
No ability for remote monitoring
HF Admission Orders
Work-load capture of remote monitoring

## Leadership & Staff

- VA Chief of Cardiology, Dr. Steven Goldman
- HF & Imaging, Dr. Elizabeth Juneman
- EP, Dr. Sergio Thal
- Interventional, Dr. Hoang Thai
- Transplant / Interventional, Dr. Reza Movahed
- HF NP, Elaine Charteris
- EP NP, Mary K Pierce
- Pacer RN, Lori Pack

**Notes:**
Leadership & Staff

VA Chief of Cardiology, Dr. Steven Goldman
HF & Imaging, Dr. Elizabeth Juneman
EP, Dr. Sergio Thal
Interventional, Dr. Hoang Thai
Transplant / Interventional, Dr. Reza Movahed
HF NP, Elaine Charteris
EP NP, Mary K Pierce
Pacer RN, Lori Pack

## Questions?

- elizabeth.juneman@va.gov
- elaine.charteris@va.gov

**Notes:**
Questions?

elizabeth.juneman@va.gov
elaine.charteris@va.gov