What began as a “Value Care Action Group” initiative in the department of medicine is now a model outpatient clinic effectively serving patients with heart failure while reducing visits to the ED.
Heart failure has always had one of the highest readmission rates of any condition and approximately 80% of patients presenting to the ED with heart failure are admitted. These are costly encounters and historically, patients have had few alternatives when their oral diuretic regimens fail. The Outpatient Diuresis Clinic at UNC Meadowmont Heart and Vascular Center was designed to offer an alternative to admission to these patients.
How the Clinic Began
Thelsa Weickert, MD, had the idea for a multidisciplinary ambulatory diuresis clinic and presented it to Darren Dewalt, MD, medical director for the UNC Department of Medicine’s Value Care Action Group (VCAG). In 2016, the clinic began through VCAG, focused on better serving patients with decompensated heart failure while also reducing visits to the ED and subsequent hospitalizations. Mirnela Byku, MD, a transplant cardiologist by training, joined the team in 2017, and she is currently leading this effort. Altogether, the clinic has served 426 unique patients, leading to 1,386 diuresis sessions since its inception on September 1, 2017.
“Many of those visits would have been ED visits were this option not available,” said Scott Keller, VCAP Business Manager. “The vast majority of patients who show up to an ED in need of diuresis are admitted, and heart failure admission is around $25k, on average. Without the option of going to the clinic, it’s unclear where these patients would go other than the ED. Yet even without knowing the savings, we know that every four admissions saved are worth about $100k to the patient/payor. In a shared savings environment, you don’t have to prevent many trips to the ED to justify an option like this, from a financial perspective.”
The success of the diuresis clinic is also attributed to its design. It was built as a co-management model, primarily managed by nurse practitioners and clinic nurses, but always having the patient’s primary cardiologist in the loop on their status and progress with intervention. This gave patients more immediate access to care. The clinic can facilitate earlier hospital discharges by addressing the ongoing diuresis needs of patients in the outpatient setting, and it has enabled UNC to reduce some inpatient hospital stays by as much as 2-3 days. From a patient perspective, this results in helping heart failure symptoms become much better controlled in an ambulatory arena. Patients are also happy not to have to go into the ED, which has proven especially useful in times of COVID.
“Advanced practice providers Emily Baker, NP, Sarah Waters, NP, and others, along with the Meadowmont cardiology nursing and support staff, have been integral to the success of this project,” said Weickert, MD. “In an increasingly resource-constrained environment, we believe this clinic successfully reduces the need for hospitalization of stable heart failure patients at a substantial cost savings. But most importantly, we are doing right by our patients.”
The team is currently in the process of measuring the effect of the outpatient diuresis clinic on inpatient utilization of heart failure patients followed by UNC cardiologists and plans to publish the results.
This project is one of many Value Care Action Group improvement efforts taken up by the department of medicine. Champions in each medicine division are currently encouraging the review of current practices, looking for improvements for high-value outcomes in healthcare. High-value is defined by the quality of patient-centered care achieved per unit of cost. Ronald Falk, MD, chair of the department created the group in 2016. Scott Keller is the director of business development keeping the team focused on value-oriented care models. Darren DeWalt, MD, serves as medical director for the team and helps define the projects. John Vargas is the project manager.
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