Results
From February to July 2021 of 58 patients with two or more HF admissions, 41 RPM-HT referrals were placed successfully, and patients were assigned a dedicated provider; the remaining 17 patients declined participation in this initiative. Three patients received their devices but were unable to set them up due to life stressors, leaving 38 patients who transmitted their vital signs and device questions successfully for at least 1 week. As of July 2021, 30 patients were actively transmitting weekly. RNs used the new HF template to document symptoms in more than 385 different notes. The initiative resulted in 43 provider-initiated diuretic changes in 21 patients and 9 pharmacist-initiated diuretic changes in 6 patients. The initiative resulted in 43 provider-initiated diuretic changes in 21 patients and 9 pharmacist-initiated diuretic changes in 6 patients. Of the pharmacist-initiated diuretic changes, five increased dosage, one decreased dosage, one restarted a patient-discontinued medication, one changed medication type and one held a medication. The pharmacist made 13 total non-diuretic medication changes, of which 5 increased dosages, 2 corrected dosages, 3 restarted a patient-discontinued medication, 1 changed medication type, 1 added a medication (empagliflozin) and 1 held a medication. Providers made 23 total non-diuretic medication changes. There were 23 total non-diuretic medication changes by providers. In four cases (four patients), providers referred patients to the ED.
As seen in figure 1A,B, there was a decrease in missed outbound RN calls per enrolled patient over time, with a decrease in the mean from 21.4% (RN PDSA 1: weeks 5–15) to 10.2% (RN PDSA 2: weeks 16–23). Special cause variation was not found.
Figure 1(A) Weekly percentage of outbond RPM-HT RN calls with HF template missed per enrolled patient over time—P chart. Averaged across all intervention weeks, the mean weekly percentage of outbound RPM-HT RN calls with HF template that were missed per enrolled patient was 14.7%. (B) Weekly percentage of outbond RPM-HT RN calls with HF template missed per enrolled patient over time—P chart split mean. We split the mean to examine changes from PDSA Cycles implemented to decrease RPM-HT RN calls missed. Weeks 1 through 4 were a run-in period, so we calculated a mean for weeks 5 through 15 (RN PDSA 1) and split this from the mean for weeks 16-23 (RN PDSA 2). Total enrolment of patients in the initiative increased over time. PDSA Cycles to decrease RPM-HT RN calls missed are annotated in the figure (RN PDSA 1 at week 4; RN PDSA 2 at week 15). Upper and lower control limits were based on three standard deviations above or below the mean incorporating the sample size for each time period. CL, control limit; HF, heart failure; PDSA, Plan–Do–Study–Act Cycle; pts, patients; RN, registered nurse; RPM-HT, remote patient monitoring-home telehealth; UCL, upper control limit.
As seen in figure 2A,B, there was a decrease in missed provider interventions per total clinically necessary provider interventions, with a decrease in the mean from 15.1% before provider PDSA 1 (week 1–15) to 3.4% after (week 16–23). From week 18 to 23 there were no missed interventions recorded, with special cause variation detected with six points more than one sigma below the mean.
Figure 2(A) Weekly percentage of clinically necessary provider interventions missed over time—P chart. Across all intervention weeks, mean weekly percentage of clinically necessary provider interventions missed was 10.1%. Special cause variation was detected (noted with *) starting at week 18 with six data points all more than 1 sigma below the mean, at the lower control limit. (B) Weekly percentage of clinically necessary provider interventions missed over time—P chart split mean. We split the mean to examine changes from provider PDSA cycle 1 to decrease clinically necessary provider interventions missed. Data was split into two periods, a mean calculated for weeks 1 through 15 (baseline) and a mean for weeks 16 through 23 (Provider PDSA 1). Clinically necessary cardiology provider interventions missed were defined as where, by project lead chart review, a call to a patient was clinically warranted to address a change in vital sign of device/template question but either no intervention occurred, or no documentation of any intervention was made in the electronic medical record. Missed provider interventions were corroborated by one provider who was also a quality improvement lead. Provider PDSA cycle 1 to decrease clinically necessary provider interventions missed is shown in figure. Upper and lower control limits were based on three standard deviations above or below the mean incorporating the sample size for each time period. CL, control limit; PDSA, Plan–Do–Study–Act Cycle; UCL, upper control limit.
Patients maximally optimised on GDMT
Over 5 months of intervention, providers’ self-assessment was that 26 ED visits might have been prevented because of their interventions. Examples included diuretic titration after non-VAGLAHS hospital admissions, diuretic titration after dietary indiscretion, provider counselling to resume diuretics after patient self-discontinuation, discontinuation of BP medication in the setting of side effects from empagliflozin and other medications, and a provider finding that an assisted living facility administered the wrong dose of diuretic daily after hospital discharge. In all these cases, providers and RNs collaborated to follow-up with patients to ensure resolution of clinical status changes.
To evaluate whether there was a statistically significant difference in ED visits pre intervention vs post intervention, for the 34 HF initiative patients actively using RPM-HT, 65 ED visits (0.16 ED visits per person-month) occurred in the 12 months pre intervention, compared with 8 ED visits (0.04 ED visits per person-month) for the 6 months of intervention. Pre intervention, 61 ED visits (93.8%) resulted in admission; post intervention, all 8 ED visits (100%) resulted in admission. There was a 75% decrease in ED visits or hospitalisations post intervention compared with pre intervention (p<0.001).
Sixteen patients with HFrEF or mildly reduced ejection fraction were referred to the pharmacist. Pre intervention, 18.8% of patients (3 of 16) were prescribed all eligible GDMT medications. At 20 weeks of intervention, this had increased to 68.8% (11 of 16) (p=0.005 for pre–post comparison, using McNemar’s test). Pre intervention, patients were prescribed an average of 65.1% of eligible GDMT medications. At 20 weeks of intervention, this increased to 85.9% (p<0.001 for pre–post comparison, using paired t-test). Pre intervention, 6.3% of patients (1 of 16) were maximally optimised on prescribed GDMT. At 20 weeks of intervention, this had increased to 37.5% (6 of 16) (p=0.03 for pre–post comparison, using McNemar’s test). Pre intervention, patients were on average 52.5% optimised on GDMT. At 20 weeks of intervention, this had increased to 77.8% (p<0.001 for pre–post comparison, using paired t-test).
Lessons and limitations
Integrating RPM-HT and pharmacist consultations into an HF-specific disease management programme is a unique feature of this initiative, in addition to the proactive weekly calls designed to detect early clinical status changes; both of these innovations contributed to our success. We achieved our aims by enrolling over 30 patients who actively transmitted RPM-HT data weekly within 5 months, and by increasing more than 50% the number of HFrEF patients maximally optimised on GDMT. Statistically significantly reduced HF admissions and ED visits for patients enrolled in the initiative compared with usual care pre-intervention demonstrates the potential financial savings for this project. Optimal adoption of GDMT has not been realised in many clinical settings limiting its potential benefits on morbidity and mortality; this study offers a pathway to increase prescription and optimisation of GDMT.17
Involving all RNs in training was essential to keep missed weekly outbound calls low, so that covering RNs understood the workflow and could call patients proactively using the template weekly (when flagged by the electronic system after RN PDSA 2). Stressing the importance of missed interventions to providers and going through root cause analyses of missed interventions together helped emphasise that intervening on RPM-HT clinical status changes (eg, sending a patient to the ED, making a medication change, or reassuring the patient/RN that the clinical status change did not warrant an intervention) could help improve patient care. As a result, this relatively low-reliability reminder actually decreased missed provider interventions.
Early stakeholder engagement allowed us to develop an HF-specific template that targeted provider needs and to redesign RN workflow to facilitate weekly phone calls accompanied by rapid, proactive, systematic communication of any clinical status changes to the patient’s provider. RNs asked if they could use the HF template for all their patients with HF, not just those enrolled in the initiative, reflecting template utility. RN and pharmacist-specific interventions helped team members share responsibility for medication titration and HF counselling. An RN said, ‘This [initiative] has really helped us excel as nurses and be more confident in ourselves. I think we are actually helping them [patients], and they are getting to trust us and be more honest with us’. The proactive weekly phone calls may have increased the quality of the patient–RN relationship, allowing the RN to more effectively collaborate with the provider to intervene when a clinical status change occurred. Providers reported improved workload as a result of the initiative, ‘This is helping me a lot. I am now spacing out my patient appointments from once a week to once every two weeks and I’m more comfortable doing phone appointments because I have the blood pressure, heart rate and the template and I can trust the information is reliable’. The initiative’s focus on engaging RN champions and pharmacist proctoring resulted in a number of staff promotions. The team consistently reported enthusiasm about the initiative and feeling aligned in the mission to improve HF care for patients. Patients overall reported positive experiences with the initiative. One provider reported improved collaboration with her patient’s adult children around changes in symptoms, ‘My patient’s son is really happy because [RPM-HT] is bridging the gap. Overall things are going really well’. One patient requested more frequent phone calls from the pharmacist as he felt the follow-up kept him on track with his medications.
Limitations include the non-randomised nature of this pilot study and the lack of a concurrent control group; a true decrease in HF readmissions cannot be attributed solely to this initiative and may be a result of regression to the mean. The RNs and pharmacist focused on both medication and lifestyle factors of HF management; however, a dietitian was not involved, which could improve dietary education. Future counselling protocols could include physical activity. This initiative brings up ethical considerations of resource allocation due to its focus on devoting higher care intensity to a small number of patients.
The initiative has been sustained beyond the collection of data for this manuscript due to leadership support for re-engineering teams to work at the top of their license and work together to decrease ambulatory care sensitive ED visits and improve care. This initiative has been expanded to accept HF patients being discharged from the ED and from the hospital. Prior research has indicated possible reductions in readmissions as a result of postdischarge telemonitoring.18 Our ED and inpatient teams have indicated an ability to discharge patients sooner due to the close outpatient follow-up and reliable team structure provided by this programme. An HF hub was created for this programme expansion where RNs are only assigned HF patients and have fewer patients assigned to them because of the increased workload. The RN workload is an important consideration and should be seen as a balancing measure to ensure sustainment of this programme. Replication of these results will likely most easily be facilitated in an integrated delivery system that can incorporate some version of RPM-HT and pharmacist consultations.