Integrated Nurse Practitioner and Pharmacist Post-discharge Heart Failure Clinic: Impact on Patient Outcomes

Abstract

IntroductionThe American Heart Association recommends implementation of integrated transition of care programs to manage patients following hospitalization for acute decompensated heart failure (ADHF). At our site, a Nurse Practitioner (NP) has been historically responsible for seeing patients post discharge in the Heart Failure Access Clinic (HFAC). Whether the addition of a clinical pharmacy specialist (CPS) to co-manage patients at the HFAC clinic leads to improved outcomes is not known. Therefore, we conducted a pilot study to assess the feasibility and potential benefits of this integrated approach.ObjectiveWe evaluated 30-day heart failure readmission, emergency department (ED) visits, and all-cause mortality in post-discharge patients who were seen in our integrated CPS and NP pilot HFAC clinic. The clinic process and CPS interventions were also assessed.MethodsPatients who were discharged from the hospital for ADHF were eligible for the pilot study if they had at least mild LV systolic dysfunction (LVEF ≤50%). In the integrated HFAC clinic, the NP determined patients’ volume and perfusion status, implemented a flexible diuretic plan, and set parameters for patients contacting the HF team. Responsibility for medication reconciliation, neurohormonal medication education, and dose optimization was shifted to the CPS. Descriptive statistics were used as appropriate.ResultsBetween 11/18/2019 and 3/10/2020, 24 visits were conducted in the integrated clinic. Our patients were predominantly Caucasian (88%), male (96%), and elderly (mean age: 70 ± 12 years). Most patients (75%) had LVEF ≤40%. The 30-day post-discharge readmission rate was 2/24 (8%), while both ED visits and all-cause mortality rates were 0%. Historically, veterans at our NP led HFAC clinic have had a 30-day readmission rate of 15.8% (data from 2019). The average time to appointment was 12 ± 8 days post-discharge with 25% patients seen within 7 days. The mean duration of the CPS visit was 36 minutes; the NP visit was 41 minutes (n=12). The CPS noted medication discrepancies in 14/24 (58%), alerted other providers for medication issue follow-up in 10/24 (42%), and identified HF inappropriate medications in 3/24 (13%). HF medications were titrated by the CPS in 13/24 (54%), and 16/24 (67%) patients were scheduled with CPS for ongoing medication dose titration. One patient (4%) was referred for tobacco treatment.ConclusionsEarly analysis indicates that the integrated HFAC leads to high-quality patient care as evidenced by a very low 30-day hospital readmission rate without ED visits or fatality. These outcomes compare favorably to our institution's 30-day readmission rate observed prior to implementation of this pilot project. Potential benefits of adding a CPS as a provider to our HFAC include medication reconciliation and education, identification of harmful drugs, and timely medication titration. Further analysis is warranted to compare the impact of the integrated HFAC versus standard of care over a longer time frame.