A Multidisciplinary Approach at the Primary Care Level Improves Heart Failure Care


      Heart failure (HF) is a complex, chronic disease characterized by high mortality and morbidity affecting more than 5 million Americans. Specialized HF clinics with multidisciplinary staff have been associated with favorable outcomes. The number of HF patients will likely exceed the capacity of these specialty clinics. Sustainable and effective programs will be needed to support a growing HF population in the primary care setting.


      A dedicated HF pharmacist and nurse team based in a primary care clinic can improve access to care, reduce hospital use, and empower patients to participate in self-care management.


      Patients from a practice of ten PCPs were voluntarily enrolled in a pilot study for HF case management based on referral from hospital discharge or their PCP from January 1 to October 31, 2012. Patients >18yrs with a diagnosis of HFpEF and HFrEF were included. The minimum intervention included early contact from the pilot team, in person patient assessment, medication reconciliation, HF education, and the development of patient driven self-care goals. Additional encounters with the patient were provided in person and telephonically as needed. The nurse and pharmacist used an institution approved care protocol. Patient demographic and clinical data were recorded and compared to their own historical outcomes prior to enrollment and to a matched cohort from different practice sites within our system as a control group. The advanced HF cardiologist also hosted three educational forums on HF for the pilot site PCPs during the pilot.


      Forty-six patients were enrolled in the program. The average time to first contact with a clinic after discharge for the intervention group was lower than the control group (2.6 d vs. 5.1 d). There was a 35% reduction in the total number of all cause admissions in the pilot patients compared to themselves in the same time period in the previous year. Of the self-care goals identified by patients, 83% were achieved by the end of the pilot. NYHA functional class improved from baseline (median 3, mean 2.4) to the end of the pilot (median 2, mean 2). Patient encounters totaled 486 (clinic = 77, telephone = 402, email = 7). A medication change occurred 174 times. Forty-nine percent of patients were non-adherent to at least one medication, resulting in 81 adherence interventions. Patients requiring the most intensive level of care shared the following characteristics: NYHA Class III, > 12 co-morbidities, >15 medications, recent HF admission.
      Surveys reflected patient and physician satisfaction with the program.


      Our data suggest that a HF nurse and pharmacist team working with PCPs under a standardized protocol can enhance access to care, reduce hospital use, and improve patient symptoms and self-care. Supporting primary care sites with specialized ancillary staff and structured education may be an effective method to serve more heart failure patients outside of tertiary care centers.