Written by: Center for Care Innovations

San Joaquin General Hospital uses Kaiser Permanente’s award-winning population health management program to care for people most at risk for heart attacks and strokes. It’s called PHASE, or Preventing Heart Attacks and Strokes Everyday.

Joan Singson, director of population health management, recently walked us through how this resource helped her team create a Congestive Heart Failure Clinic. 

Asking Questions

This journey started at a project meeting. A provider asked, “How can we better serve our patients who have congestive heart failure?”

The team stopped, looked at each other, and pledged to look into it.

By digging into the hospital’s data, they discovered that congestive heart failure patients who were being seen in the primary care clinic were actually going to the emergency department when they were feeling troubling symptoms. And then, quite frequently, they were being admitted to the hospital.

Then the team asked the nurses focused on managing complex care in the hospital’s new population health management department the same question: “What are you finding?” The nurses said they were observing that patients and their families were leaving the hospital overwhelmed and confused. Despite receiving detailed discharge summaries, they didn’t understand doctor’s recommendations or how to take the medication.

Before: How It Used to Work

The team investigated the current treatment of these patients. Typically it goes like this:

  • A patient is diagnosed with congestive heart failure. Sometimes this happens after a trip to the emergency department.
  • The hospital’s complex care nurses get an alert when the patient is about to be discharged.
  • A nurse makes an appointment for the patient at the primary care clinic.
  • The nurse then will call the patient multiple times, in between their visit to the hospital and upcoming clinic appointment, to make sure the patient is OK and that the family is well supported.
  • This nurse is now the patient’s “bestie,” noted Joan.
  • A few days before the appointment, the health coach will call the patient to remind them and ask if any transportation needs to be arranged.

Piloting a Special Clinic

This system clearly wasn’t cutting it. The team concluded patients needed more points of contact. So they developed a plan and got leadership’s blessing to try a special clinic — what would become the Congestive Heart Failure Clinic.

The team rolled up their sleeves to restructure their work, piloting different iterations.

They added health education, patient navigation, and health coaching. They developed self-management tools for patients and health status assessments for the health coaches.

“And to be honest, all these tools that we developed remain in draft form today,” said Joan. “Why is that? Because it’s constantly evolving, right? The way we provide service constantly evolves, and that I think is one lesson that we need to keep in mind.”

They also expanded the care team to include a pharmacist and dietician. And they did it without adding new staff.

“What we did was we agreed to restructure workflows and to review resources that we had,” Joan said. “We all had to relearn how to interact with each other in the clinic, and we looked at the talent, the capacities, the resources, the services that we add in-house and how to pull that in.”

After: Treating Robert

When Robert was discharged from San Joaquin General Hospital, Robert had “very little hope in his heart, figuratively and literally,” said Joan. He was using a wheelchair. He was swollen. He was severely fatigued and almost constantly out of breath. All symptoms of his condition, congestive heart failure. His wife actually was probably thinking out loud when she asked the question, “He’s going to die, isn’t he?”

Robert became one of the first patients at the Congestive Heart Failure Clinic. And initially he wanted nothing to do with the staff. He told them, “Not interested. Leave me alone.”

But the staff didn’t leave him alone. Joan reported that they started leaving Robert “unscripted, gooey messages.”

  • “Hi Robert. How are you doing? Hope you’re doing okay. Let us know if you need help, okay?”
  • “Hey, Robert. You’re due for your 10-day appointment after your discharge. It’s on Monday morning with Dr. Heartbeat. Don’t forget. And bring your medications so that the pharmacist can go over the medications with you.”

As a result, Robert actually showed up to his appointment. As soon as his wheelchair crossed through the clinic doors, here’s what happened:

  • The registration clerks welcomed Robert and alerted the medical assistant in the backroom.
  • Then the medical assistant greeted Robert and his wife in the clinic hallway and recorded his vitals.
  • Next, the health coach joined them in walking Robert back to the exam room. The coach asked questions like, “How are you doing with your blood pressure today? What’s been troubling you? Are there any questions that you might have for the doctor? Let me help you write those down.”
  • Just as that was completed, the pharmacist walked in and started asking about Robert’s medication.
  • Soon the congestive heart failure doctor arrived, reviewing the updated patient record. Together, they discussed Robert’s current treatment plan.
  • This whole time, the nurse had been in the hallway. She then came into the exam room and Robert was finally able put a face to the person who has been leaving him so many voicemails.
  • The nurse introduced Robert to a dietitian to explore options for changing his eating habits and overall wellness.
  • There was also a psychiatrist on hand to help and perhaps refer Robert to other services.

Gone is the “bestie” nurse, said Joan. This expanded team leaves patients like Robert and his wife feeling supported and confident they can handle congestive heart failure.

Lessons Learned

After patients visited the Congestive Heart Failure Clinic, overall hospital admissions for those patients dropped by 76 percent. Put another way, for every four hospital admissions of congestive heart failure patients, this special clinic eliminated three of them.

Joan’s takeaways:

  • Data is your friend. It’s also a necessary driver for these efforts.
  • Listen to your patients. What makes them happy? What complaints do they have?
  • Build on what you already have. Resources, organizational capacities, etc.
  • Brainstorm and remain flexible. There are other interventions out there. There’s not one way to do this.
  • Focus on the patient. The patient may very well benefit from having a “bestie” nurse, but Robert’s whole care team is committed to Robert’s care. And that’s what makes a difference.

“Robert, the last time we saw him, walked through the clinic doors,” said Joan.



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