When HF patients are admitted, they often face inconsistent care among the three to eight different hospitalists and cardiologists that care for them. UPMC’s CHF Hospitalist program sought to create consistency by developing a standard order set and having one provider care for patients across hospital visits.

CHF hospitalists work together to establish protocol

Currently, the CHF hospitalist team consists of four physicians and three Advanced Practice Providers (APPs) who are passionate about improving outcomes through frequent patient rounding and communication. At every visit, the team checks and tracks key information through a standard template. All care team members can start a patient on HF medications, unlike many health systems that rely on cardiologists to do so. The CHF hospitalist team currently abides by HF guidelines, including the “four pharmacological pillars” of HF care: diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, and Lanoxin. CHF hospitalists only contact other specialists when intervention is necessary to ensure that added expertise will positively impact the patient.

Current team members became comfortable with protocol by six to twelve months. To make changes to the protocol, team members conduct literature reviews and discuss the protocol alterations. For instance, when a new medication comes out (e.g., SGLT2 inhibitors), the team discusses how to use those with new patients. The frequent cadence of communication and dialogue helps the team find what is best for patients. Further, by collaborating, the staff have natural buy-in for agreed upon protocols as well as a regular opportunity to advocate for worthwhile changes.

Patient information from multiple visits is tracked through a standardized template

UPMC’s CHF hospitalist program aims to pair any returning patients with the same CHF hospitalist from their previous admission, to keep care consistent. CHF hospitalists track important information about the patient through a specialized template unique to the program. The template includes:

• Clinical records (e.g., current heart failure medications, HF order set, most current echocardiogram, number of admissions in the last year)
• Cause of case exacerbation (e.g., diet choices, non-compliance with medication, poor family support)
• Co-morbidities (e.g., baseline renal function, CKD stage)
• Social support (e.g., financial restraints, home status)

The information is manually inputted into patient charts so that if a patient is readmitted to UPMC Harrisburg, their previous inpatient visit information will be readily available to any admitting provider and their designated member of the CHF hospitalist team. This ensures patients receive care that is in line with previous clinical recommendations so they can recover as smoothly as possible.

For many inpatient stays, patients see their physicians once daily for a brief period of time. CHF hospitalists round on their patients multiple times a day, building a strong relationship for ongoing education and goal setting that spans the entirety of the patient’s care journey.

CHF hospitalists round frequently to make patients familiar with them and HF information

CHF hospitalist staff round at least two to three times a day for 20 to 30 minutes. By using this time to fully understand the patient's condition and medications, CHF hospitalists build trust with their patients. The CHF hospitalists also educate not only their patients, but also their patients’ families on their condition (e.g., HF stage) and the tasks necessary to prevent readmission. For example, a CHF hospitalist may walk a patient through scenarios on what to do if they are delayed from taking their medication. Family members who are present can also learn from this conversation and ask questions as needed.

Prior to discharge, CHF hospitalists will reemphasize crucial information and practice scenarios with patients and families. By working with patients and their support systems repeatedly, CHF hospitalists can underscore healthy behaviors.

In developing a close relationship, CHF hospitalists can have serious conversations with patients and elevate necessary discussions on downstream care options

Given how familiar CHF hospitalists are with their patients, they can candidly discuss future care pathways with patients and their families, especially if there have been multiple admissions. One of these topics is end-of-life care. Through their integrated relationship, CHF hospitalists are well-equipped to help patients and family members discuss if transitioning to hospice may be right for them, independent of busy palliative medicine staff who do not have a relationship with the patient. These conversations can empower patients and their families to decide on the best course of action for the patient's health.

Overall, UPMC has found that patients become so close with their CHF hospitalists, that they can comfortably discuss their current condition, what is best for their treatment and care goals, and actionable next steps.

High readmission rates are often attributed to patients not receiving subsequent care according to their treatment plans. UPMC’s CHF hospitalist program ensures that these gaps are filled for patients leaving the hospital with a comprehensive follow-up plan.

CHF hospitalists establish post-discharge touchpoints

After discharge, HF patients are monitored via in-person or telemedicine visit with their primary care physician or cardiologist. The CHF hospitalist program bridges the gap between discharge and this appointment by conducting post-discharge telemedicine visits 24 to 72 hours after the patient leaves the hospital. CHF hospitalists ask about any problems with acquiring or taking medication and answers any questions the patient or their family may have to promote treatment plan adherence.

Future directions to bridge discharge and follow-up care

In the next few years, the CHF hospitalist program hopes to work with UPMC’s hospital-at-home program to check on patient progress after discharge. Post-acute care doctors will go to the patient’s home and follow-up within two weeks post-discharge or until patients attend their follow-up appointment. This can track and improve patient health in a setting familiar to them.

The partnership will pilot administering diuretics in the home so that patients can receive this care in a setting more comfortable to them. Further, patients at home would be monitored regularly while receiving this additional follow-up care to avoid CHF exacerbation.