Abstract 146: Medical Home Model in the management of Heart Failure

Abstract

Purpose: Heart failure (HF) continues as the most expensive diagnosis to manage in the US. Patient failure to adhere to medication regimens and fluid overload have been identified as causative factors in frequent exacerbations requiring hospitalization. This study was designed to evaluate outcomes over time of a Medical Home interdisciplinary team management and patient education design compared to standard of care in HF. Methods: The study was designed as a prospective case-control study. Enrollment occurred post HF hospitalization. During hospitalization all pts received education in Guideline-driven management of HF, and were discharged on evidence-based medications. Patients provided informed consent allowing review of medical records for 5 years. One group of pts agreed to participate in a Medical Home for the management of HF (MHHF) while another group chose management of HF by their own cardiologists. Data analysis was performed using case controlled pairing of pts based on age, gender and socio-economic status. Data represents results at 48 months. The Intervention group (22 pts: mean age 60.8) was followed in a MHHF which includes a HF specific clinic and a 12 week comprehensive HF management and exercise program (both clinic and HF management program have the same disease management protocols) and the Control group (48 pts: mean age 62.2) returned to standard follow up care for HF. In MHHF medications were optimized per evidence -based recommendations and education included use of medications, diet and effective sodium balance. Results: Functional Capacity Results: Medication adherence/Hospitalizations/ED visits Note: * baseline to 48 months. Hosp. visits = # hospitalizations/yr/ patient, ED Visits = # ED visits/yr/ patient. Medical record review of medication use for Standard of Care pts failed to provide adequate information on dose /patient. **Adherence was often self reported so true adherence may be lower than reported for this group. Conclusions: 1. Patients participating in MHHF demonstrated long-term improvement in medication adherence and smoking cessation. 2. Patients participating in MHHF demonstrated significantly fewer HF related Hospitalizations and ED visits 48 months following their baseline hospitalization.