Innovations in Outpatient Care of Heart Failure. Robin J Trupp PhD, ACNP-BC, CHFN Duke University Hospital System Durham, NC

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Innovations in Outpatient Care of Heart Failure Robin J Trupp PhD, ACNP-BC, CHFN Duke University Hospital System Durham, NC Innovation Function: noun 1 : the introduction of something new 2 : a new idea,
Innovations in Outpatient Care of Heart Failure Robin J Trupp PhD, ACNP-BC, CHFN Duke University Hospital System Durham, NC Innovation Function: noun 1 : the introduction of something new 2 : a new idea, method or device If an invention improves some product, process or service for the public, then that invention transforms into an innovation There are always barriers to intervention, including resistance to change, existing culture or lack of new inventions Recent Innovations in OP Care Transitional Care Teams HF Observation Units Device Diagnostics Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128: Accessed online June 27, 2013. Transitional Care Team Goal: An integrated, holistic, macro view of the needs of the patients, instead of reacting to data in a patchwork fashion Includes medicine, nursing, case management, pharmacy, home care, patient-caregiver, and others as needed CMS introduced TOC reimbursement codes Moderately complex: face-to-face visit within 14 days Complex pt: face-to-face visit within 7 days Discharge Orders, Pending Tests, Red Flags Reinforce self management/care Specific instructions regarding red flags Complete medication reconciliation Resources needed upon return to community Communication of care delivered, plan of care, outstanding tests, etc to next providers of care Timely and comprehensive Identification of Captain of the Ship Fermazin M, Tahan H, Lett II JE, et al. Improving transitions of care: emergency department to home. Available at All Rights Reserved, Duke Medicine 2007 Accessed August 12, 2013. Observation Units (OUs) OUs have emerged as a viable solution due to limited ED bed capacity or lack of inpatient beds OUs are associated with readmission reduction initiatives Treatment provided in OU does not count as a readmission; no limit on number of OU visits Must be medically necessary significant risk of deterioration in the immediate future Pts incur greater out-of-pocket expenses than if had been admitted Also fail to meet requirement for skilled care A HF OU Must Be located in an acute care setting Provide a bed and periodic monitoring by professional staff Assess / reassess response to treatment Have LOS of at least 8 hrs to max of 48 hrs Time frame intent to assist with determining medical necessity and to reduce denials Adequate document need for admission for those failing to meet discharge standards IF care required can only be delivered in IP setting Transition Care Team is imperative AdaptivCRT Algorithm Regular rhythm? no yes Evaluate intrinsic conduction A yes Intrinsic Intrinsic AV conduction AV conduction present present? and normal? Any HR? no LVp Adaptive LV pacing Optimal AV Delay? Adaptive BiV pacing Optimal AV and VV Delay? RVs Medtronic Viva XT CRT-D manual. Adaptive CRT Trial 1 : Results End Point Secondary End Points at 6 months acrt (n=318) Echo (n=160) ΔLVESVi (ml/m 2 ) -8.3 ± ± 24.2 ΔLVEF (%) 3.9 ± ± 9.8 ΔNYHA -1.0 ± ± 0.8 Δ6-min HW (m) 42.4 ± ± ΔMLWHF QoL ± ± 23.8 * - non-inferiority p-value Difference (95% CI) 2.3 (-2.8, 7.4) 1.0 (-1.2, 3.1) (-0.3, 0.0) 13.4 (-8.9, 35.7) -1.7 (-6.3, 2.8) P-value* (Margin) (15) (-2.5) (0.3) (-30) (5.1) 1. Martin DO, Lemke B, Birnie D, et al. Investigation of a novel algorithm for synchronized left ventricular pacing and ambulatory optimization of cardiac resynchronization therapy: results of the adaptive CRT trial. Heart Rhythm. 2012;9(11): AdaptivCRT Reduced AF Risk by 46% As compared to patients receiving echo optimized CRT % Patients with 48 Hours of AT/AF 50% 40% 30% 20% 10% 0% p = 0.03! HR = 0.54 ( )! Months Since Randomization Echo! 8.8%! acrt! Number remaining ! 16.2%! 1 Martin D, Lemke B, Aonuma K, et al. Clinical Outcomes with Adaptive Cardiac Resynchronization Therapy: Long-term Outcomes of the Adaptive CRT Trial. HFSA Late Breakers. September 23, Closing Innovation has nothing to do with how many R&D dollars you have... It's not about money. It's about the people you have, how you're led, and how much you get it. Steve Jobs
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