Über die Autorin bzw. den Autor

Michael E. McIvor, MD, FACC; Medical Director, St. Petersburg Heart Center; Medical Director, Foundation Research; Director, Heart Failure Program, Bay Pines VA Medical Center.

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With the growth of independent heart failure clinics, practitioners and administrators alike are facing a host of new questions. In this unique reference. Dr. Michael McIvor draws on his personal exprience to help you:

• Determine the staffing and physical facilities your program will need
• Delineate management and day-to-day staff responsibilities
• Assemble the financial projections that are critical to a fiscally sound program
• State the goals, scope, and strategies and tactics of your program in a business plan
• Identify clinical and financial benchmarks for measuring success
• Construct telemanagement protocols that match your treatment style
• Develop the treatment algorithms, drug protocols, and standing orders you will need
• Position your program for success in your community

Establishing a Heart Failure Center: The Essential Guide will help you develop a program that will reduce hospitalizations, optimize medical therapy, and enhance patient quality of life.

Aus dem Klappentext

With the growth of independent heart failure clinics, practitioners and administrators alike are facing a host of new questions. In this unique reference. Dr. Michael McIvor draws on his personal exprience to help you:

• 
  
• Determine the staffing and physical facilities your program will need
  
• Delineate management and day-to-day staff responsibilities
  
• Assemble the financial projections that are critical to a fiscally sound program
  
• State the goals, scope, and strategies and tactics of your program in a business plan
  
• Identify clinical and financial benchmarks for measuring success
  
• Construct telemanagement protocols that match your treatment style
  
• Develop the treatment algorithms, drug protocols, and standing orders you will need
  
• Position your program for success in your community

Establishing a Heart Failure Center: The Essential Guide will help you develop a program that will reduce hospitalizations, optimize medical therapy, and enhance patient quality of life.

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Establishing a Heart Failure Center

John Wiley & Sons

Chapter One

Your practice or hospital has been treating heart failure (HF) patients as long as you have been in existence. We now know some of the limitations of how we have treated HF in the past, and more effective ways to approach this disease have been identified. However, before proceeding with the effort and investment of setting up a new way of doing things, you will want to be sure that a formal HF program is right for your patients, your practice, and your community.

Is a heart failure program right for your patients?

Heart failure (HF) remains a challenging condition to treat. In fact, it is sometimes even a difficult condition to define. Nonetheless, HF remains a cardiac epidemic, afflicting 5 million Americans, with 500,000 new patients joining this cohort each year. It has taken some time for us to accept that HF is not the episodic disease that it at first seems. It is in fact a chronic, progressive disease punctuated by episodes of decompensation. While our initial clinical focus was on stabilizing a patient's hemodynamics during these decompensations, it has become clear that many therapies that reduce HF symptoms do not impact long-term prognosis. The pillars of HF therapy are now aimed at improving survival rather than simple symptom relief. Getting a patient on a regimen of evidence-based doses of the neurohormonal antagonists, though, is not easy. One is always fighting hypotension, hyperkalemia, the cardiorenal syndrome, and so on. The titration of the medical regimen does not end when target doses are achieved. As in many chronic diseases, patient management is characterized by ongoing up- and down-titrations as the clinical picture changes. It is difficult for a physician working alone to maintain the schedule of very frequent visits needed by the patient with advanced HF.

Getting a heart failure patient on a regimen of evidence-based doses of therapy is not easy

In addition, the value of patient self-care in HF is well established. In the brief encounters that patients have with physicians during an office visit, teaching a patient about sodium budgets, fluid budgets, and self-management of diuretics is very challenging, if not virtually impossible. In our program we say that the new math of HF is that 7 x 1 = 0, and 3 x 3 = 2. In other words, if we teach seven things to a patient once, he or she is likely to retain nothing. If, on the other hand, if we teach three things three times, we can expect most patients to remember two of them. Unfortunately, in the current healthcare environment, the pressure on physician time necessitates that this time be spent on activities that require the training and experience of a physician. Patient education is not one of those activities that can only be performed by a physician. Therefore it will always be a lower priority (than say, a cardiac catheterization or a transesophageal echocardiogram, which do require a physician), no matter how important education is to patient outcomes.

The use of heart failure programs has now risen to the level of national guidelines

The practical choice with which we are left is to provide incomplete care or to leverage physician resources by using nonphysicians. The latter is preferable, and the emergence of formal HF programs to meet this need is no longer new or unproven. In fact, the use of HF programs to deliver care has now risen to the level of national guidelines. The 2005 American College of Cardiology/American Heart Association guidelines give the highest level of recommendation to treating HF patients with formal HF programs:

Multidisciplinary disease-management programs for patients at high risk for hospital admission or clinical deterioration are recommended to facilitate the implementation of practice guidelines, to attack different barriers to behavioral change, and to reduce the risk of subsequent hospitalization for HF.

The 2006 Heart Failure Society of America guidelines likewise support the use of HF programs [2]:

Patients recently hospitalized for HF and other patients at high risk should be considered for referral to a comprehensive HF disease management program that delivers individualized care....

The acceptance of the superiority of this new model of care represents an international paradigm shift. The 2005 update to the European Society of Cardiology HF guidelines also addresses not just the therapy to use in HF, but how to deliver that care:

An organized system of specialist heart failure care improves symptoms and reduces hospitalizations and mortality of patients with heart failure.

While there is general agreement, then, that the preponderance of evidence supports the widespread adoption of HF programs, there are a number of specific approaches that have been put forward, none of which has proven to be the superior method of managing HF patients. Low-tech and high-tech telemanagement systems, hospital nurse case managers, home health HF nurses, and dedicated HF clinics have all met with varying degrees of success. In this book I will present my experience with my own programs and with others I have seen be successful. Other types of programs may also be effective, but I know firsthand that the methods presented here can improve patient outcomes.

Is a heart failure program right for you?

It is one thing to know the strengths and weaknesses of various approaches to HF care. It is quite another to know which approach will work for you. The premise of this book is that the most cost-effective and clinically effective way to treat chronic HF in adults is a formal HF disease management program. In spite of my personal enthusiasm for the disease management strategy, after talking with physicians across the country, I have learned that this approach will not work for everyone. You may be accustomed to being the sole caregiver for patients under your charge. The shift to managing an HF team that provides this care is a big step philosophically and emotionally. The skill set required is different than what I acquired in medical school and requires spending a considerable amount of your professional time being a program builder, a teacher, and an administrator. The physician still drives a disease management program. However, in the model I propose here, there are on average four patient contacts with nonphysicians for every physician contact. In traditional models of care, all the responsibility ultimately rested on the doctors' shoulders. That is still true, but in the disease management model, much of the decision making is done, and much of the care is delivered, by nonphysicians. This makes some physicians very uncomfortable.

In the disease management model, there are four patient contacts with nonphysicians for every physician contact.

A reasonable analogy here is the military. While the admiral carries ultimate responsibility, and it is his or her decision to move the fleet from point A to point B, the admiral doesn't physically steer the ship. Everyone knows the chiefs run the navy. The first "go/no go" decision in considering the establishment of your HF program, then, is to know yourself and your style of patient care. If you must be both the admiral and the chief, if you can only be comfortable if you control all...