- Coordinated, team-based care management strategies are making a major impact on the way patients receive treatment for cardiovascular conditions, including heart failure and pulmonary embolisms (PE), according to several recent case studies.
By developing better communication between staff members and a more comprehensive approach to standardizing treatment protocols, team-based care management strategies may help to prepare providers for value-based reimbursement while boosting their chronic disease management and acute care competencies.
At Allegheny General Hospital, for example, a new pulmonary embolism response team, nicknamed PERT, brings together cardiologists, pulmonologists, critical care specialists, and radiologists to address the third-most-common cause of cardiovascular death.
“The number of pulmonary emboli (PE) that we’re seeing at Allegheny Health Network (AHN) is on the rise. We saw over 2,500 cases of acute PE just at Allegheny General Hospital alone last year,” said Raymond Benza, MD, Medical Director of the Pulmonary Hypertension and Thromboendarterectomy Program at AGH.
The team leaps into action as soon as an acute PE is discovered during a diagnostic test, a press release explains. The radiologist involved in the discovery contacts a pulmonary expert, who performs a rapid risk assessment and notifies the patient’s primary care team.
If the assessment determines that the patient is at moderate or high risk of harm from the condition, he or she is brought to an intensive care unit. The team then conducts a comprehensive evaluation and decides on the best course of treatment.
“Before this new team-based approach, there was no clear pathway, so many of the patients were not getting consistent, guideline-based care,” said Eric Bihler, DO, a pulmonary and critical care medicine specialist at AGH. “This led to substantial delays in therapy for those who had the most serious kind of PE that must be treated like a stroke or a heart attack, where a delay in care can be deadly.”
Massive or sub-massive PEs have a 60 to 70 percent mortality rate without timely and aggressive treatment. The symptoms of the condition can be commonly mistaken for other problems, and patients may not receive care from the right specialist quickly enough to avert a serious problem.
“The Pulmonary Embolism Response Team is a perfect example of how important it is to use a multidisciplinary, team-based approach when treating a disease that can be difficult to diagnose and doesn’t clearly fall into one particular medical specialty,” said Srinivas Murali, MD, Director of AHN’s Cardiovascular Institute.
“With the PERT, physicians from various medical and surgical disciplines, bringing different perspectives and areas of expertise to the table, are quickly able to collaborate and develop an agreed-upon pathway of care, then gather the resources required to execute that treatment plan efficiently, thus achieving the best patient outcomes.”
The intervention strategy has been so successful at Allegheny General Hospital that the health network is planning to roll out the team-based care management approach to other facilities in the eight-hospital system, officials said.
Meanwhile, at Holy Name Medical Center in New Jersey, nurse practitioners (NPs) are playing an increasingly important role in heart failure management, according to a study published in Nursing Economics late last year.
The NP Care Model bridges the gap between clinical care and case management by providing concierge-type services to patients and their caregivers.
“The activities of the clinical concierge include coordinating care delivery and aligning health care objectives, clarifying disparate care plans, reviewing and presenting diagnostic treatment options to patients and families, providing education regarding therapeutic alternatives, referral to hospice/palliative care as applicable, assisting in preparing patient and care team for discharge planning and follow-up disposition, monitoring of the EHR…and organization of family and team meetings as needed,” explains the article.
This comprehensive suite of patient management services, combined with a focus on making sure that patients are engaging in self-care as much as possible, has produced significant cost reductions, fewer 30-day readmissions, and long-term improvement for patients.
Compared to a control group, patients participating in the program experienced 18 percent fewer 30-day readmissions, and 26 percent fewer readmissions at 90 days from discharge. Fewer avoidable admissions resulted in a savings of nearly $700,000 over control group levels.
“Successful management of patients with heart failure was provided by a NP-led multidisciplinary team in concert with primary care providers or cardiologists,” the study says. “Contributions by NPs can be maximized by deliberately and thoughtfully integrating their practice into the organization’s culture.”
Patients in need of acute care for life-threatening conditions, including heart attacks and strokes, can also benefit from an integrated, coordinated approach to treatment. At the University of Maryland Medical Center (UMMC), a new critical care unit is providing a novel way for non-trauma patients to receive intensive treatment when an ICU bed isn’t immediately available.
The Critical Care Resuscitation Unit, which opened in 2013, mirrors transfer protocols and the design of a unit already established for trauma patients. Fewer formalized guidelines for non-trauma patients meant that some critical cases had to wait in the ED or other settings not equipped to handle the highest levels of care.
The 6-bed CCRU fills the gap by acting as a short-stay ICU, staffed around the clock by physicians and other clinicians with broad experience in clinical care.
“We built the CCRU to address the inefficiencies inherent in relying on a particular ICU to accept a transfer,” said Thomas M. Scalea, MD, FACS, a trauma expert at UMMC and a professor at the University of Maryland School of Medicine.
“ICUs are designed to manage patients for the entire course of their stay and they are highly specialized according to disease. The CCRU is for the immediate resuscitation, evaluation and disposition of all transfer patients. That is only part of what an ICU can do, but it’s the only thing the CCRU does.”
The unit has helped to increase transfer rates by 64.5 percent, and cut arrival times nearly in half, from 234 minutes to 129 minutes, according to data published in the Journal of the American College of Surgeons.
“We admitted nearly 1,000 additional transfer patients in the first year alone since opening the CCRU,” said senior author James O'Connor, MD, Professor of Surgery at UMSOM and Critical Care Chief at UMMC. “Adding just six beds and borrowing practices we had honed in the Shock Trauma Center made our entire system more efficient.”
Co-author Lewis Rubinson, MD, PhD, Associate Professor of Medicine at UMSOM and Director of the CCRU, calls the unity a “new niche for resuscitation medicine.”
“It’s a paradigm change but easily adaptable for other academic medical centers,” he added. “While we were fortunate to model the CCRU on a similar system already in place for our trauma patients, the fundamental principles are universal.”
Developing standardized processes to identify patient care concerns in a timely manner is a critical component of good patient management for acute and chronic care alike. By creating multi-disciplinary protocols that take a team-based approach to care delivery, providers can ensure that their patients are receiving the most appropriate services in a timely manner to produce better outcomes across the board.