Table 1

Quality improvement initiative workflow steps and description

Workflow stepDescription
Patient identificationPatients with two or more VA hospital admissions with a primary diagnosis of HF in the last 365 days are eligible for this initiative
Cardiology provider assignmentEligible patients are assigned to dedicated cardiology provider
EnrolmentCardiology provider asks patient about their interest in enrolment in initiative
RPM-HT RN assignmentIf the patient agrees, an RPM-HT referral is placed and an RPM-HT RN is assigned
Baseline phone callRPM-HT RN calls the patient, asks HF template questions for baseline and orders the wireless monitoring equipment
Data transmissionsThe patient sets up their equipment and starts wirelessly transmitting their vital sign data and answers the device-generated selection of general health and symptom questions daily
Proactive weekly callsRPM-HT RN calls patient weekly, asks HF template questions and documents in EMR. Calls continue regardless of whether patient is continuously transmitting wireless data (eg, patient goes on vacation, is out of town, or has not received or been able to set up equipment yet)
Calls for red alertRPM-HT RN calls patient when responses are outside ranges specified by the referring provider (a ‘red alert’), asks HF template questions and documents in EMR
Clinical changes communicated to providerIn weekly calls and red alerts, RN reviews and analyses the data and if there is a change in clinical status, formulates a clinical assessment and communicates that assessment to the cardiology via a secure instant message or phone call in addition to an EMR note that includes the answers to the HF template questions
Provider interventionThe cardiology provider reviews the information and triages whether an intervention is needed (eg, medication change to aid symptom resolution, call to send the patient to the ED or clinic, or decision that an intervention is not needed)
Clinical status resolutionThe cardiology provider notifies the patient and/or RPM-HT RN and documents their findings in the EMR, follow-up is continued until resolution of the clinical status change
Referral to HF pharmacistProvider may refer enrolled patients to HF pharmacist for medication reconciliation, management and GDMT optimisation
Pharmacist monitoringThe pharmacist monitors and assesses patient vital sign and weight data to help predict the patient’s volume status and determine the need for medication counselling and the candidacy for GDMT titration
Pharmacist phone callsThe calls the patient twice monthly and as needed for follow-up using a pharmacy-specific HF template that includes pharmacy-specific outcomes and interventions to document telephone calls with patients
Collaborative decision-making with cardiology providerThe pharmacist and a designated cardiology provider meet weekly to collaborate and discuss patient care and GDMT optimisation and changes for enrolled patients. All medication changes are collaboratively made with a cardiology provider. The HF pharmacist also has the ability to meet the patient and join discussions during the patient’s visits with their cardiology provider.
  • ED, emergency department; EMR, electronic medical record; GDMT, guideline-directed medical therapy; HF, heart failure; Pharmacist, clinical pharmacy specialist; Provider, licensed independent provider; RN, registered nurse; RPM-HT, remote patient monitoring—home telehealth; VA, veterans health administration.