7 Key Strategies to Optimize Heart Failure Management Across the Continuum

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7 Key Strategies to Optimize
Heart Failure Management
Across the Continuum

Health Catalyst Editors

Article
Summary
Heart failure treatment is complex and requires ongoing
attention. To ensure organizations are delivering optimal
treatment to prevent disease, slow progression, and
improve outcomes there are seven key strategies across
the continuum of care to deliver guideline-directed
medical therapy and engage patients in their care.

The Opportunity to Improve Heart Failure Healthcare
Heart failure (HF) impacts 6.2 million adults in
the United States and has negative physical
and emotional consequences, resulting in
poorer quality of life and increased morbidity
and mortality. Treating HF is complicated and
dependent upon severity of disease and
comorbid conditions. It requires different
treatment protocols, ongoing titration,
optimization of therapy, perpetual
assessments, remote patient monitoring, and
lifestyle changes. Without all these
interventions, mortality and morbidity
increase, hospital stays are lengthened, and
unnecessary hospital readmissions occur.
Heart Failure Treatment
6.2 million adults in the
United States

A Comprehensive Approach
to Heart Failure

A Comprehensive Approach to Heart Failure
The recently published 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure provides
treatment recommendations for each of the four stages of HF — from patients who are at risk for HF
to those who already have advanced disease. To deliver effective care, healthcare organizations need
a comprehensive approach. Through optimal care, organizations can prevent HF, slow disease
progression, improve the quality of life for patients, and prevent hospitalization and readmissions.
Here are seven strategies to improve HF care and impact outcomes and the patient experience:
 Closely Follow Guideline-Directed Medical Therapy
 Focus on Prevention at the Population Health Level
 Standardize Acute Inpatient Management
 Minimize Risk During the Transition of Care to Home
 Monitor Patients Post-Discharge
 Collect Data Using Remote Physiologic Monitoring (RPM)
 Empower Patients as Active Participants in Their Care
Seven Strategies to Improve HF Care

HF disease progression can be slowed and patient outcomes
can be improved when guideline-directed medical therapy
(GDMT) is closely followed, yet the data shows this often
doesn’t happen. That may be due to a variety of reasons:
 Physicians may not be aware of regular updates to the guidelines
 It may be difficult for organizations to identify at-risk and
rising-risk cohorts
 Effective discharge processes may not be in place
 Transition of care planning may be incomplete or inconsistent
 Overburdened care teams may not have the bandwidth to
conduct the recommended follow-up
 Patients may not adhere to care plans
Leveraging technology and more rigorous processes across the
continuum can bridge these gaps in HF care delivery and
ensure compliance with GDMT.
1. Closely Follow Guideline-Directed Medical Therapy

Data analysis is an essential population health
initiative to identify patients who may be at
risk for developing HF, including those with
high blood pressure, high low-density
lipoprotein (LDL) cholesterol, diabetes,
smoking and secondhand smoke exposure,
obesity, unhealthy diet, and physical
inactivity. Armed with these data,
organizations can develop programs designed
to modify lifestyle behaviors that may include
primary care initiatives, community and
school programs, individual wellness
coaching, and direct consumer engagement.
2. Focus on Prevention at the Population Health Level

For those with an existing diagnosis of HF,
cohort stratification into stages (Class I through
IV) based on left ventricular ejection fraction
(LVEF) enables analysis of compliance with
GDMT, including pharmacological and non-
pharmacological therapies. An enterprise view
of deviation from guideline-based patient
management enables the identification of
patterns that may form the basis for action,
such as training, distribution of monthly
performance dashboards, creation of remote
physiologic monitoring programs, evolution of
nurse navigator protocols, and more.
2. Focus on Prevention at the Population Health Level

A HF hospital admission, as noted in the AHA/ACC/HFSA report, represents a
critical opportunity to continue, initiate, and further optimize GDMT. However,
the CHAMP-HF (Change the Management of Patients with Heart Failure) registry
identified many eligible patients with a reduced LVEF who were not prescribed
guideline-informed therapies.
Standardization of inpatient care protocols across an organization, IDN, or
network represents a crucial improvement activity and includes:
 Triage processes
 Laboratory and electrocardiographic testing
 Cardiac imaging evaluation
 Medication therapies including circulatory support and prophylaxis
 Monitoring
Alerts and notifications can serve as reminders to frontline staff when there is a
deviation from GDMT. They can ensure that the appropriate tests are being
ordered and medications are being paused, delivered, or titrated.
3. Standardize Acute Inpatient Management

Enterprise-wide dashboards driven by
robust data and analytics can support
clinical leaders in identifying
unwarranted care variation by
location, provider, and patient cohort.
Filters and drill-down capabilities are
useful in analyzing the root cause of
variation, therefore pinpointing
improvements that will likely have the
largest impact on clinical outcomes,
operational efficiencies, and revenue.
3. Standardize Acute Inpatient Management

HF patients are most at risk during transitions from one care setting to
another. The hospital-to-home transition is particularly problematic, with
very high rehospitalization and mortality rates occurring after HF discharge.
Implementing structured telephone support after discharge,
multidisciplinary HF clinics in the community, and care transition
interventions such as home visit programs involving pharmacists and nurses
can reduce readmissions and mortality.
Transitional care plans initiated prior to discharge define patient-centered
instructions with a clear plan for transitional care. It’s also an opportunity to
address high-risk characteristics associated with poor post-discharge clinical
outcomes and plan for medications, follow-up, and at-home monitoring.
Leveraging a technology solution can help automate these tasks through
checklists and care team alerts.
4. Minimize Risk During the Transition of Care to Home

Medication adherence and care plan compliance are also common post-discharge
concerns. Many organizations are realizing success with automated digital patient
communication and engagement pathways that aim to overcome challenges:
 Insufficient education about disease process, medical plan of care, and benefits of
medications or therapies
 Poor understanding of complex treatment regimens
 Difficulty managing medication side effects and HF symptoms
 Overcoming social determinants of health that prohibit adherence
 Lack of motivation for lifestyle modification activities
 Complicated logistics for follow-up visits and medication titration
 Fragile patient-provider relationships and lack of trust
Real-time, automated care team notifications based on patient engagement
parameters also support intervention to prevent further exacerbation that leads
to ED visits and hospital admissions.
4. Minimize Risk During the Transition of Care to Home

It’s important to monitor patient health and titrate
GDMT medication dose every 1–2 weeks to achieve
treatment goals and prevent readmission. However,
the continual compression of inpatient length of
stay complicates medication monitoring. To initiate
and optimize treatment after hospitalization, an
ambulatory clinical communication pathway can
assist with ensuring the completion of medication
reconciliation, follow-up phone calls from the care
team, scheduled clinic appointments, and
identification of barriers at home.
Initiating care management and navigation services
can serve as added support for patients who face
significant barriers or are living with severe illness.
Care teams can better ensure patients receive
timely care and avoid rehospitalization or death.
5. Monitor Patients Post-Discharge

Remote cardiac monitoring encourages patients to
be proactive in their care. Noting changes in daily
readings supports smarter decision-making about
their activity levels, diet, and lifestyle choices. RPM
is also a simple and effective way for healthcare
providers to keep track of disease progression and
provide early intervention.
There are a variety of ways to deploy RPM. For
patients identified in the at-risk group, a simple
blood pressure monitoring pathway can be
automatically deployed via patient engagement
technology. It can support the patient in obtaining a
blood pressure monitor, remind them to submit
their BP readings on a regular basis, and deliver
information like dietary tips and encouragement to
make lifestyle changes.
6. Collect Data Using Remote Physiologic Monitoring (RPM)

It’s also very important for HF patients to
monitor their weight, blood pressure, and
symptoms. Automated text messages can
prompt patients to report barriers such as
lack of access to a weight scale or difficulty
obtaining prescribed medications.
This real-time feedback enables
optimization of treatments, early
intervention when needed, slowed disease
progression, and improved outcomes.
6. Collect Data Using Remote Physiologic Monitoring (RPM)

HF patients with low activation can
experience negative outcomes, including
higher 30-day mortality, and patients at
the lowest activation level had a more
than sixfold increased risk of death within
30 days of hospital discharge compared
with patients in the highest two activation
levels. Furthermore, most patients
hospitalized with HF have low activation,
and therefore lack the skills, confidence,
and motivation to manage their own
health. They also tend to be less satisfied
with their care and more often require
skilled care at hospital discharge.
7. Empower Patients as Active Participants in Their Care

Maintaining a connection outside of a clinical or hospital setting is
essential for patients who are at risk for HF – whether it’s to monitor
physiologic data, provide education and encouragement, or connect
patients with resources. For patients who are at risk for HF or are
already living with this progressive disease, organizations must find
creative ways to engage patients between visits to ensure compliance
with GDMT, conduct serial assessments, monitor patient-reported
outcome measures, and dynamically adjust medications and therapies
based on evolving patient conditions.
Empowering patients can also ease the ongoing healthcare staffing
challenges. Nurse navigator activities can be supplemented with
patient engagement strategies. The automated delivery of simple text
messages makes patients feel more cared for, and based on patient
responses, care teams can be alerted about potential deterioration
and provide early intervention.
7. Empower Patients as Active Participants in Their Care

Improve Heart Failure Outcomes
with the Power of Technology

Improve Heart Failure Outcomes with the Power of Technology
A comprehensive approach to HF is essential to meaningfully
prevent the disease, slow progression, improve the quality
of life for patients, and prevent hospitalization and
readmissions. Compliance with national guidelines for
management of patients with HF is challenging for many
providers given their complex and evolving nature. The
opportunity to optimize care delivery spans the continuum:
 Population health initiatives to reduce the incidence of disease
 Acute decompensation management in the inpatient setting
 Care transitions including discharge to home or transitional
care settings
 Ongoing ambulatory care to prevent exacerbation and
improve quality of life
A Comprehensive Approach to HF

Improve Heart Failure Outcomes with the Power of Technology
Technology is a powerful ally in the quest to improve HF outcomes. Providers
face mounting pressure to deliver GDMT amidst a staffing crisis, while also
lacking actionable data to drive decision-making. Effective strategies to optimize
patient outcomes, decrease mortality and morbidity, reduce hospital length of
stay, and prevent unnecessary hospital readmissions include:
 Comprehensive data analysis to identify patient cohorts with HF risk factors
 Activation of patients in their care with consumer-friendly engagement technology
 Standardization of protocols and processes within electronic systems to manage
acute decompensation
 Alerts and notifications about deviation from expected courses of action
 Dashboards and analytics to monitor performance and differentiate between
warranted and unwarranted care variation
 Remote physiologic monitoring that empowers patients and informs care teams
A Comprehensive Approach to HF

1 Comprehensive Heart Failure Improvements Lead
to Reduced Readmissions, Mortality, and Costs
3 Using Analytics to Automate Heart Failure Data Aggregation
2 Remote Monitoring and Digital Patient Engagement
Improves Blood Pressure Control
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4 Improved Care Transitions Reduces Readmissions
Saving $3.2M Annually

7 Key Strategies to Optimize Heart Failure Management Across the Continuum

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