The 18th Annual Building Partnerships for Healthier Hearts Conference is designed to address cause, diagnosis, and treatment strategies of heart and vascular disease, which is still the number one cause of death in the United States. Many patients suffer from multiple forms of heart and vascular illness.
This program is intended to provide a team approach to care for heart and vascular diseases.
The Heart and Vascular Center of Excellence at Wake Forest Baptist Health is a national leader for the comprehensive, collaborative, systematic, and evidence-based care of patients with heart and vascular diseases.
Through a multidisciplinary partnership of healthcare professionals from various departments and sections, we are better able to provide high quality and a more effective delivery of care.
Wake Forest Baptist Health offers cutting-edge diagnostic and management strategies for heart and vascular care, many of which will be discussed in this conference.
PAMELA W. DUNCAN: I came to Wake Forest Baptist Health two years ago to work with the CEO and the COO in some of our challenges in readmissions. And I brought to this position an academic career of understanding what patients look like in the home, and what post-acute services are available, and what's not deployed when it needs to be. Now you probably also know me from the front page of the "Winston-Salem Journal," repeatedly when we're challenged at Wake Forest Baptist Health by our readmissions. I've been on NPR, I speak nationally, and I want to share with you today that I know that you're sitting in a cardiovascular conference, but the diagnosis is not congestive heart failure. I also served as a CMS Innovations Advisor. And I want to speak for a minute with you about policy and where we are so that you can understand what we are doing at Wake Forest Baptist Health to re-engineer health care. And we'll have, eventually, an effect on congestive health failure. But first of all, let me talk to you about policy for a minute. We are in a major crisis in health care. The cost of health care is astronomical. I just did an analysis in Forsyth County for a CMS proposal and found that in Forsyth County if you have a stroke, the cost of post-acute services is two and 1/2 times higher than the acute hospitalizations. And oh, by the way, if you're Medicaid and have a stroke, the cost of skilled nursing for rehab is $40,000. And if you don't recover, the cost is a $60,000 annual nursing home placement. That's $100,000 for post-acute services for a Medicaid in Forsyth County. That's not including the admissions, and readmissions, and the doctor visits, and the medicines that they need. So you can understand that what we have to do is to begin to think about how we're going to control and manage post-acute care cost. CMS has been very targeted on managing acute care cost and physician cost. But now they're shifting to the post-acute arena because we, as a country, cannot sustain that level of increase in patient care. So then you might ask well, what does this have to do with readmissions? And let's talk about this from a policy perspective. When CMS rolled out their penalties for readmissions, they chose three conditions, congestive heart failure, pneumonia, and AMI. Now they made a mistake by choosing AMI. But why do you think that they really chose congestive heart failure, pneumonia? And they just released that they're going to add COPD and stroke. So why do you think they chose congestive heart failure, pneumonia, stroke, and now COPD? Because those are the conditions that cost the most to Medicare and Medicaid. And as you will see from our own data and the data from this community, the diagnosis is not congestive heart failure. And if we try to manage congestive heart failure readmissions in the population that's causing us the most financial stress, we will fail. So let me begin by saying that what we're doing at Wake Forest is we're trying to re-engineer health care to meet the next generation of changes that are coming. But let me tell you a little bit-- and probably, in this room, I don't need to tell you very much-- is that Wake Forest Baptist Medical Center is a tertiary academic medical center, like Duke, UNC, East Carolina. And we are what Medicare calls a safety net hospital. We have a disproportionate amount of Medicaid patients and Medicare-Medicaid dual eligible, and we have a high proportion of uninsured patients. Now when you look at every report that's come out about readmissions, the number one driver of readmissions, actually, is socioeconomic status. And they will not allow us to adjust for that. We adjust for medical complexity, but we do not adjust for sociodemographics and the challenges that I'm going to share with you this morning. Now, again, that's not necessarily wrong. It just says that we're going to have to build another system to manage both medically and socially complex patients if we're going to decrease the cost of health care in this country. Now, again, going forward, in Winston-Salem and Forsyth County, Wake Forest Baptist Health runs Downtown Health Plaza and an outpatient clinic. The Downtown Health Plaza is the third largest Medicaid population in the state of North Carolina, and 6% of Downtown Health Plaza Medicaid visits are contributing to 49% of the ED visits. Now we have another segment of the population called the outpatient clinic. And 91% of the patients that we see in the outpatient clinic are aged, blind, and disabled. And what that means is-- that's the classification in Medicare and Medicaid-- is that you have the most complex medical conditions. And many of them are under the age of 65. That's a population that we see, and 13% of these patients are contributing to 72% of all ED visits. Oops, didn't meant to do that. So when you look at data, and let me tell, it's retrospective. So the front page of the "Winston-Salem Journal" just lambasted us again. And I'm not defending that or opposing that. It is the reality. That's retrospective analysis. When CMS implemented the penalties for readmissions, they did not do it prospectively. They went back from 2008 through 2011 before the Accountable Care Organization Act was ever implemented. So today when you see that posting in "Winston-Salem Journal," or on the CMS website, that data is three years old. And now they've moved it up through 2011. So, you know, you can't catch up with a ballgame that was already played. Now again, it's just challenging us. And CMS, in my opinion, did that with a purpose. Pay attention. Pay attention, Wake Forest Baptist Health. Pay attention, Duke University. Pay attention, Scotland Neck. You've got to deliver care to your population differently than you've done it before. And we're going to penalize you now, and you better move fast. But as you will see, we are moving. But moving fast in complex social and medical situations is like the Child No Left Behind policy in education. So I want to tell you six take home messages as I go forward. First, managing complex. patients is a community challenge. And that's the way we approached it when I came to Wake Forest two years ago. All challenges are local. Challenges in readmissions are specific to your medical facility. The challenges in readmission in Forsyth, or Moses Cone, or Wake Forest Baptist Health may be quite different, but there's one common thing. We all live in the same community. And the challenges are at the community level. And if you think that someone's going to come in, and somebody knocks on my door-- and I'm not exaggerating-- at least every week and tells me that they have the solution. And most of them are third-party payers. Oh, if we just do teach-back. Oh, if we just tell them to weigh themselves. Oh, that will work. Well, in some patients it well. But in our most frequently admitted patients, I can tell you, it's part of the solution. Managing the medical symptoms is part of the solution, but managing the complexity of comorbid conditions and social issues is a broader one. But when you get these major challenges, you have to begin to say where am I going to hone in? Where are going to be my strategic priorities? But I can tell you that Wake Forest, we are integrating medical and social services to make this work. But for those of you who are physicians in the room, raise your hand. There is no paste around for a good physician. Forget it. Sometimes I believe that what I do sitting on the eighth floor at Janeway Tower is a Bandaid for what we used to call good medicine. At the end of the day, the patient needs a doctor. They need a doctor who knows them, that's engaged with them, and can deploy the resources that they need. Those of you who are from this area know the famous physician Eugene Stead. And he wrote a book called "What This Man Needs is a Doctor." The patients still need a doctor. And they need a doctor who understands them in the community and also can communicate with the big towers of hospital practice. And this degeneration of patients want to hear the doctor. Now the doctors have to be able to lead the teams. And going back to the old days of the country doctor where he knew everybody in town, and he knew your social problems before you got to the hospital is probably not going to happen. But without physician engagement and nursing leadership, we will not solve this problem. I want to pause for a minute and acknowledge people who really have been major leaders with us as we looked at it in congestive hearth failure-- Fran Charlton, Susan Butler, Stacy Thomas. We, in a very short period of time in a pilot study, were able to significantly reduce congestive heart failure readmissions because we brought nursing, pharmacy, care coordination, medicine, and cardiology together to think about the complexity of the management. And you're also going to see when we engage physician leadership with good interdisciplinary teams, we can reduce readmissions in the most complicated patient population. So there is no substitution for physician presence and physician leadership. I just came from a presentation in Michigan and spoke to the associate dean of the new medical school there. And he said, I just talked for the entering class. And he said, your role is not to ask the question what the diagnosis is not. It's to ask the question what the diagnosis is. So we have set up a broken health care system throughout the country where we have specialist after specialist. It's not that diagnosis. Now it's your turn. It's not that diagnosis. It's your turn. And I won't get into the personal situation, but I've just experienced that in a very dangerous situation with my husband. Passed from the cardiologist when it wasn't a heart attack, to the hospitalist on an observation unit, to a surgeon. And the only way I got coordinated care with all the knowledge I have was to look at the surgeon in the face and say, would you please take charge? So those are the things that we have to accept responsibility for at all levels of practice. And we have to think about how we're going to practice in a very different system. So let's go back to the issues in this region in Forsyth County, in Stokes, in Surry, and Davie, and Davidson, and Wilkes. When I came here, I knew that CMS was going to release what they call the 10th Scope of Work. And the 10th Scope of Work was to take hospitals and communities that have the highest readmission rates, and determine what's causing them, and to work with the community to develop community partnerships and collaboration. That 10th Scope of Work was released the 1st of August of 2011. And I was sitting in Cary, North Carolina on August third with colleagues from Forsyth to say here we are. Wake Forest Baptist Health, as you read the newspaper, has had some of the worst readmission rates in the state and in the country. And oh, by the way, when you look at the community, we all do. So come to our community, help us figure out what's driving it. So throughout my year, I've been a very well-funded researcher. And I can tell you, if I had done this on NH dollars, it would have cost me probably $4 million, and I would have given you the results in about three years. But with the power of CMS and their data, and Medicaid and their data, and the partnerships in the community, we delivered the results in three months. And we did it from multiple strategies. First of all. If you're representing a hospital, you don't really know what your readmission rates are. I, this morning, don't know what my readmissions rates were from last month really because I only have access to my data. Now because of a project I have, in a few months, I can tell you what it is throughout the community. So we use that opportunity to understand when patients bounce back from Forsyth or Wake Forest. We begin to understand. We use claims data, both Medicare, Medicaid. We ran focus groups with patients. We ran focus groups with physicians. We looked at medication reviews. We had focus groups with interdisciplinary providers. We brought in our care coordinators, and we heard the challenges that they face as they try to manage this population. We began to understand. So let me tell you who congestive heart failure patients are. First of all, the diagnosis is not congestive hearth failure. That's the symptom. You should ask the question, what are the diagnosis? The patients who are frequent flyers are patients with end-stage renal disease, diabetes, atrial fib, glaucoma, hypertension, and congestive heart failure. CMS in their infinite wisdom chose congestive heart failure, because if you're old and complicated, all of you know there are three ways out as your elderly-- pneumonia, congestive heart failure, and a hip fracture. Right? So our challenge is not just managing congestive heart failure, but it's managing very sick, complicated patients. And many of these patients have major socioeconomic challenges. We also geomapped the readmissions in this region. And guess where they're coming from. The largest density of readmissions are coming from East Winston-Salem and the rural areas with low socioeconomic status. And some of you are shaking your head. The bedside nurses, you know it. You see them, right? Just last week-- I ride in the field with our navigators. We may provide the best services, and you may do teach-back, and you may think they understood what you said. But did you really do a cognitive screen? And when I get in the home, did they remember a thing you said? Nope. And what we found in a pilot study at Wake Forest, and the Geriatric Cardiologist said Pam, this can't be right. You've done the test wrong. I said no, sir. Come and do it yourself. A patient can converse with you and can repeat what you said, but managing 16 medications requires recall, attention, and executive function. And many of these patients are never screened for their cognitive ability in the hospital. And what we found was major presence of not minimal, but moderate cognitive decline. And when we get in the home, they don't remember a thing you said, not that you didn't do it right. But they're confused. It's not about medication reconciliation, you guys. It's not about checking off a list. It's about is there somebody in the home who understands and can support the patient and family to manage their medicines? We've had many psychosocial challenges. We're working very closely with Medicaid because Medicare, Medicaid has the highest risk of readmissions compared to Medicare. What percent of these patients carry a behavioral health diagnose? Not schizophrenia all the time, but depression, and they are not always management for that. So we have a lot of mental health issues that are driving it. And if there's one thing I'm going to ask you-- and I'm going to give you cases-- many of these patients are really at the end of life. I just read our 13 readmissions, 66 plus, came in my email. I'll read every one of them since last night for last month. We had eight with a diagnosis of congestive heart failure. And let me tell you-- I'm going to show you a case in a minute-- they were all multiple complex, end of life diabetes, you name it. And no one's engaged in that conversation with what are your goals of care? The first patient was a very elderly patient. It wasn't congestive heart failure. It was AMI, quote unquote. And it was in this third readmission that we got around to talking to the patient and family about what are your goals of care? There's really not much more that we can do for you here. What do you need? Now all of you sitting on the front row know the barriers to doing that on the front lines. You've got a hospitalist over here the family's never seen. And are they going to listen to a doctor they've never seen to bear the message? What we're asking our physicians at Wake Forest Baptist Health to do is to begin to recognize the issue, and deploy the conversation in the community, and send that message forward with the primary care physicians and our palliative and Hospice services. Many of these patients are not going to die tomorrow. They don't need Hospice. But they're probably going to die in the next year. And how do you start engaging the conversation with the patients and the families about really, what are your goals? And what do you want? And how do we mobilize the community resources to deal with that? And last, but not least, many of the patients and family may actually refuse our suggested services. Again, we respect, that is their right. But how many of you in this room have said I will never go to a nursing home? Raise your hand. Right. So when we approach the subject of the 89-year-old elder and the 85-year-old wife, and the 89-year-old man may have reasonable cognitive function, but feel physically impaired. And he doesn't want to send his wife to the nursing home. And the daughter lives in New York, or California, wherever. It takes time to assimilate that message about maybe the nursing home placement isn't forever, but we could send you there for a short period of rehab. The community doesn't understand the difference between skilled nursing placement versus long-term nursing placement. And you nurses are like this. Everybody's task oriented. Do it, do it, do it, do it, do it, do it, do it, do it. You know, in my recent husband's situation, and sitting there with the bedside nurse, I said you seem to be documenting this very well that his blood pressure is now 200 over 100, and his heart rate's dropping, but what are you going to do about it? So it's not about just documentation. It's about bedside critical thinking and engagement with the patient and the family, and beginning the conversation, and having what we are developing at Wake Forest Baptist Health, the mitt to catch it. You can't do it in today's brief hospitalization. So straight off the press from last night, these were my notes from a colleague. This was one of our eight congestive heart failure readmissions. Been readmitted three times in the last month, was just readmitted 9/1. Primary reason, congestive heart failure, has a history of atrial fib, end-stage renal disease, diabetes, glaucoma, hypothyroidism, and she's had six hospitalizations in the past year. End-stage renal disease, and no discussion anywhere about what the patient's goals of care are. And she keeps coming back in with volume overload. So what we have to do to really solve our issues not for Wake Forest Baptist Health and gets us off the front page of the "Winston-Salem Journal." I am way too old in my career to be worried about that. But what I am worried about is what's going to happen to me I get old? I already am, you guys. We've got to think about how we want care to be delivered. We've got to empower a health care system to engage physicians, and front-line practitioners, and communities to work together. And we want the care that's cohesive and integrated. This idea, when you're carrying end-stage renal disease, congestive heart failure, high blood pressure, and diabetes-- today you see the cardiologist. And the next admission is the hospitalist. And the third admission is the nephrologist. And, in fact, we are totally transparent at Wake Forest Baptist Health. When Fran Charlton and I looked in our studies about multiple readmissions, I can tell you, it was a rare exception, rare, that a patient ever came back to the same service. And, in fact, nationwide-- no offense if you're a hospitalist-- but we have become shift workers. Got my shift, 12 hours, got seven day turn. And when the patient comes back, that shift worker isn't there. So how do we think about providing other ancillary advanced nurse practitioners and others to help embrace a new model of care? And, oh Lord, when we looked in the community, the biggest source of readmissions was coming from home health. Now we can say we have poor home health in this community. Actually, we don't. We have good home health. They go in the home. They pick up the problem. The nurse sees the medication issues. Patient's gaining weight, call the primary care physician. Oop, can't see them. Didn't know they were here. They're not on my tenure today. Call the hospital, doctor's office his shift. So we call it the Bermuda Triangle. Home Health goes out there. They see a declining patient that could be managed in the home, but without physician orders and oversight, you cannot do it. So where do they go? The ED. And if you come to Wake Forest Baptist Health, more than likely if you get through our ED, you're going to get admitted. Now some people may say that's a challenge. But we don't have any sign on I40 that says we've got a 10-minute wait at Wake Forest Baptist Health. [LAUGHTER] Our ERs are 100% full with people who are using the ED for primary care. And even when we have primary care for them, guess what. One gentleman said to us the other day oh, the only automatic dial I have on my phone is 911. Now that is true. I am not making this up. So we are Trauma One Center. We've got to keep our ED really mobile because if you are picked up on I40-- and ED doctors, they don't know how to deal with these routine cases. That's not what they're trained for. So again, we are thinking about-- and I'm thinking we are beginning to implement a different strategy in our ED. And even though that we have-- and this is a regional problem from my data from CMS-- even though we make the appointment for the patient, guess what. They don't show up. Some of them are way too sick to go back to the doctor. And even when we're providing transportation, nah, I'm feeling better today. I don't need to see the doctor. And then we have the problem now of mail order pharmacy. So we get in the home. The physicians have written the right order of Lasix at that point. And now we need to readjust things, and we need a new medication, but mail order. Well, we need the medicine now. And they may not be able to afford it now. But last, but not least, the most disturbing thing has just occurred. Durable medical equipment in this state and nationwide is only provided now by certain providers. Guess what they've made durable medical equipment, glucometers, needles, and the sticks. Do you know how many times we've been in the home recently, two cases, where they had insulin, but they didn't have the needles? And they didn't have a way to check it. And they don't have immediate access to it. That was the infinite wisdom of Medicare trying to control the cost. So what are we doing here at Wake Forest Baptist Health? I am not on a journey, as much as some of our colleagues might want at Wake Forest, to try to change this yesterday. I can't change yesterday. But we can go on a trajectory of change that will substantially help the care of our patients. First of all, we collaborated in the community through the Northwest Triad Coalition with all the hospitals, Forsyth, Home Health, the Palliative and Hospice care. And we now have-- and I want to invite all of you to that. November 1st will be a massive AHEC. We have bound together as a community to start to deal with these integrated community challenges. And the first thing we did-- we were the first one in the state of North Carolina to get a CMS grant to send social work navigators out to the home to pick up these social problems so that we could activate the appropriate resources. So in Forsyth, Davey, and Davidson county right now, we have access to social workers. We certainly have a bigger demand then we can meet. And Medicare is actually paying for a service call right at home, which is that bridge between short-term social service needs and long-term application. So we can provide you transportation. We can even clean your house. We can get you food. So we are deploying those. It looks like we got our first quarter report that we may have decreased community-wide readmissions, all calls, all condition by 5% in the first quarter, but we want to see if that's sustainable. Wake Forest Baptist Health announced this week-- and it will be in the press in the next week-- we have engineered a new model of home health care. I've spent my career researching home health and post-acute services, and it's not a very functional system. It's not functional to send nurses and therapists in the very fragile patient's home without integrated physician leadership. So we now have rolled out, effective September 16th, Wake Forest Baptist Health Care at Home. And we have integrated geriatric stroke neurologist leadership. And we round with the home health team biweekly on their most complicated patients. And if they get in the home, and they find a problem, they have a one-stop number that a Wake Forest Baptist Health physician will respond to you. We've been piloting this over the last few months. And I can tell you, If we can get the patients to home health, we can reduce readmissions significantly. I'm going to come back to that issue. Can we get the patients to home health? So that is a new model of care that's very different than how home health agencies have worked in the past. We're bringing in incredible leadership, the Sticht Center on Aging, the best geriatrician, internal medicine, integrated leadership. And we are already doing it in stroke to help manage those patients when they get home. We also found that, if we looked at readmissions in this community, there are five nursing homes that are really contributing to the bounce-backs. And I bet you all of you locally can name one of them real quick. And you say oh, that's horrible nursing home care. Well, who are the patients that they're treating? They are the most challenged nursing home, but they treat the patients that most of the nursing homes won't take. When I was growing up in rural North Carolina, my mother used to say don't ever send me to the county home, right? You know what the county home was. Well, the nursing homes that are treating the county home patients have multiple challenges. So we at Wake Forest Baptist Health have taken our geriatric team, we have established a transitional care unit, our patients who are admitted at Wake Forest Baptist Health, our doctors are there to see them and to manage them. We have established relationships with four other nursing homes in the region where we're partnering with the nursing home physicians, and we're creating what we call transitional care units so that they'll have immediate access to the highest quality medical care that you can imagine. And we have just joined alliance with Kate B. Reynolds. We have totally re-engineered our palliative care organization within the health care system. And it's amazing the results that we have in our Hospice conversion ratio. And it's all about physician leadership and engagement. And last, but not least, we have developed a primary care practice called Care Plus. The physician in today's reimbursement strategy can't possibly manage all the complex issues before him. And it's not in these most complex patients, a simple medical home. You have to be able to identify your high-risk patients. You may need go to see them in the home, send mental health social workers, community health workers, or nurse practitioners. If they don't come see us, we'll go see him. This is a public health crisis. So we have to treat it like a population health management. So that program, again, very implemented. So let me just tell you about frequently admitted patients. They are the ones who are contributing to all your metrics and readmissions. And again, the most common diagnosis among them are congestive heart failure, COPD, end-stage renal disease, and diabetes. And the number one diagnosis that has the highest risk of readmissions is end-stage renal disease. It's 1.4 odds. And Wake Forest Baptist Health really owns all of the dialysis centers in this region. And we have a high volume of end-stage renal disease. So we have 16 dialysis units, and in 2012 there were 1,534 admissions to Wake Forest Baptist Health for patients with end-stage renal disease. Nationwide, those readmission rates are over 32%. Now I'm going to brag for a minute because there is a sign out on I40. We have probably the most stellar nephrology program in the country. It's rated number nine. Barry Freedman and that team has one of the best nephrology programs in the country. So when they really began to understand the challenges in end-stage renal disease and readmissions, they took the responsibility. We're going to take charge, and we're going to take command, and we're going to reorganize our care to be more effective. And they did just that. Physician engagement, physician leadership with the nurses, they engaged the emergency department, they engaged hospital nurse case management. They started really integrating the medical records from the dialysis centers. They found some very quick-fixable things. End-stage renal dialysis patients may come in with an infection, for example. And they don't come on the nephrology, but somebody put them on the wrong medicine, these no-medicine lists. That's one example. But they also found that a lot of patients-- as you know, these are very challenged patients-- they may not sit there long enough. So the next thing they do is they show up at the ED. And we now have a program where if they come to our ED, they can continue their dialysis there rather than be readmitted. They really started personal communication across continuum with all the physicians, with the dialysis centers, with all the nurses. And they say it every Friday, that stellar team, and reviews all their readmissions, and what could they do different? What has happened in doing that, they reduced readmissions 32% to 24%, a 20% reduction in readmissions in just over a year. As I mentioned, we've built this Care Plus mode of partnerships as done in collaboration with the Northwest Community Care Network of North Carolina and Wake Forest Baptist Health. We've also brought in CenterPoint to help manage the behavioral issues. We are sending in mental health social workers into the homes as that's indicated. And we are going to treat approximately a panel of 400 patients that have three or more admissions each year. That Care Plus team is an interdisciplinary team of physicians, nurse practitioners, licensed social workers, a registered nurse, community health social workers, and pharmacy. Now you cannot deploy this in every primary care practice in town. It is not financially feasible. You can only do this in this highest-risk population. And, in fact, what we know is that this is the only evidence-based model, both from the Kaiser Family report, and-- --of North Carolina. And our purpose is a little bit different than other faith-based missions. It is really to align the faith communities and the networks at that point of the most immediate need. Is the patient getting the right door, at the right time, ready to be treated, and not alone? You know, I feel very privileged in my life that I grew up in rural North Carolina where you knew one neighbor from one county line to the other. You had the same country doctor all your life. The community knew each other. And if someone was hospitalized, the community was there at the end of the day to help you manage the situation. But society is no longer like that. And we think about community missions. And we can go to Honduras and Nicaragua. And those are great missions. But we've got a mission right here in Forsyth County. And mobilizing churches beyond their immediate congregation is one of our goals, is to make sure that there's someone there with them that can help them get the food they need. And also, in my honest opinion, and that's all it is, the palliative care end-of-life conversation really should start in the faith-based community. There are no death squads in Washington. And we certainly don't have any at Wake Forest Baptist Health. But we do have compassionate care. And that sign on our facility, we don't turn patients away. But we are going to have to manage them differently. And I want to thank all of you in this room and in this community in joining us in this effort. Thank you very much. [APPLAUSE]