Clearwater, Fla.-based Empath Health has developed a new population health management program focused on heart failure patients that provides a continuum of services from home health care, palliative care and hospice.
The program’s palliative care and hospice staff, including clinicians, home health aides and volunteers receive specialized training in caring for the unique symptom management needs of heart failure patients throughout the course of their illness, including advanced therapies such as intravenous medication, weight management and support for patients using mechanical circulation devices, pacemakers or implanted defibrillators, or patients awaiting transplants.
The program operates on a palliative care model including interdisciplinary teams, advance care planning and detailed conversations with patients and families about their goals and wishes for their care.
“Our nurses and interdisciplinary teams are trained to pick up the subtle changes that these patients can experience,” Janet Roman, Empath Health’s recently appointed director of cardiac program, told Hospice News. “Everyone will receive condition-specific training regardless of whether or not they provide direct patient care. For example, sometimes the patients will have too much fluid on board that can cause difficulty breathing or cause swelling. It can create a great deal of discomfort. Our staff are trained to pick up on these issues and address them.”
Roman will oversee the program and its implementation. As a board-certified advanced practice registered nurse with additional nursing certifications in advanced heart failure and hospice and palliative care, she will be providing and supervising much of the training.
Program staff will in turn educate patients and families on how to manage their conditions, such careful regulation of sodium intake, medication management and the volume of fluids the patient can safely ingest.
Nurses conduct a “kitchen day” with the patient and family where they discuss the patient’s nutritional needs, prepare meals appropriate to the patient’s dietary restrictions and discuss how the family’s preferred food products might positively or negatively impact the patient’s health.
The United States sees 700,000 new heart failure cases annually, research indicates, and heart failure patients have the highest rates of hospital readmissions by diagnosis, contributing to health care costs that exceed $40 billion annually. These patients also have high rates of emergency department utilization.
Cardiac conditions are the second-most common diagnoses among hospice patients, second only to cancer, according to the National Hospice and Palliative Care Organization, representing nearly 18% of the 1.5 million Medicare beneficiaries who received hospice care in 2017.
“Heart failure patients in hospice need a little more than the standard palliation of symptoms that most patients receive,” Roman told Hospice News. “It’s common for patients to cease some medications, such as blood pressure medication for example, when they enter hospice. But these patients’ hearts can’t effectively circulate blood if the pressure is high. In hospice our program continues the patients’ medications and advanced therapies consistent with symptom management.”
Empath is currently caring for more than 300 hospice patients that have a primary or secondary diagnosis of health failure in a region that includes both rural areas and urban centers. This is in addition to their patients who receive home health care.