Keep It Pumpin Business Plan-7

Business Plan:
Keep It Pumpin Heart Failure Management

CASEY WUSTERBARTH & KELLY VAN BERKEL
TABLE OF CONTENTS
Keep It Pumpin
Heart Failure Management
Executive Summary
Rationale
Heart Failure (HF) is a major health problem with the United States and accounts for nearly 2% of all health
care expenditures, which is estimated at an annual cost of $33 billion dollars and is projected to more than
double in cost by 2030. The costs primarily stem from the ever-increasing cost of HF hospital admissions,
which have more than doubled to average $20,000 per visit. These visits can be reduced significantly if a
proper disease management program is implemented and result in 5.7 fewer hospital stays per patient,
reduction in readmission rate (%25), and potential patient savings between $2,000 and $6,000 per year. There
are currently no established HF management programs in the state of WI that utilize all components of selfmanagement.
Program Description
Keep It Pumpin Heart Failure Management will provide each patient the best standard of care, acknowledging
that each patient is unique and are his or her plan of care. Therefore, our Heart Failure (HF) management
program will work with the patient to develop an individualized treatment plan (ITP) based on the
recommendations provided by the American Heart Association (AHA), American College of Cardiology (ACC),
and the American College of Sports Medicine (ACSM). This individualized treatment plan will focus on three
core components; (1) Exercise, (2) Self-management care, and (3) Patient Education, all of which are identified
as core components of a specialized cardiac rehabilitation program. Out HF multidisciplinary management
team will consist of: Cardiologist, Nurse Practitioner, Registered Nurse, RCEP, Clinical EP, and Dietitian.
Target Population
According to the CDC, approximately 4,300 individuals with Medicare reside in the Milwaukee area with HF.
Keep It Pumpin Heart Failure Management will target the 1,000 HF patients that St. Lukes Medical Center
admits each year. Of the 1,000 HF patients, Keep It Pumpin will enroll 170 HF patients that fall under the four
HF classes established by the New York Heart Association.
Services & Memberships
Keep It Pumpin Heart Failure Management services include:
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Individualized Treatment Plan
Patient Education
Exercise Sessions
Heart Failure Follow-Up
Self-Management Care
Dietitian Sessions
The program offers 3 different levels of memberships that target the needs of all HF patients. The following
memberships are available:
-
Premium Membership
$400/month
Standard Membership
$200/month
Basic Membership
$100/month
TABLE 9. Break-Even Analysis

Revenue
Keep It Pumpin Memberships
Costs
Operational/Expendables
Results:
Total
$476,500.00
Total
$388,680.00
$87,820.00
Program Description
Mission Statement
Keep it Pumpin is dedicated to providing excellent cardiac care and inspiring a new hope through our one-ofa-kind approach to treating all classes of heart failure
Values
Hospitality We strive to make interaction welcoming, attentive, and compassionate
Excellence We devote ourselves to continuous improvement, quality, and innovation
Ambition We aspire to offer the highest quality of care that results in positive patient-centered
outcomes
Respect We honor the individuality of all our patients, recognize their uniqueness, and enable the
development of each patients full potential
Teamwork We acknowledge that all staff members offer specialized qualities and talents and that only
a team can enhance our patients outcomes
Services
Keep It Pumpin Heart Failure Management will provide each patient the best standard of care,
acknowledging that each patient is unique and are his or her plan of care. Therefore, our Heart Failure (HF)
management program will work with the patient to develop an individualized treatment plan (ITP) based on the
recommendations provided by the American Heart Association (AHA), American College of Cardiology (ACC),
and the American College of Sports Medicine (ACSM). This individualized treatment plan will focus on three
core components; (1) Exercise, (2) Self-management care, and (3) Patient Education. These three core
components are identified as crucial aspects to a specialized cardiac rehabilitation program for HF patients
(1,2,3). A general cardiac rehabilitation program focuses on only two of the three core components needed for
HF patients; thus, stressing the need for an individualized disease-specific management program that focuses
4
also on the exercise training (16,19). Recent research on exercise training in HF patients has been shown to
produce positive effects on functional class, quality of life, and mental depression (2,3,9,36),. By following the
general exercise guidelines for HF patients, provided by the AHA; functional class can be increased by 1 full
NYHA or more, quality of life scores can increase by 10 points or more, and an overall decrease in depression
scores can be observed (2,16,21,33,35,38,42,49). Based on this research, our heart failure disease
management program will help patients fully understand the purpose and value of their treatments and work
with them to overcome their barriers. The ultimate goal of this heart failure care management program is to
give the patient the highest quality of care possible and to keep the patient empowered to provide themselves
with quality self-management care at home.
Target Population
The prevalence of HF in Wisconsin is demonstrated below by the rate of hospitalizations per 1,000
Medicare beneficiaries displayed in the figure below. According to the graphical representation of WI, the
Milwaukee area has one of the highest heart failure hospitalization rates; specifically being 17.4 per 1000
Medicare Beneficiaries (31). Due to the high prevalence of HF in this area, the target population of Keep It
Pumpin Heart Failure Management will be adults over the age of 65, with a general diagnosis of stable chronic
heart failure and any NYHA classification. The specific eligible ICD codes for these HF patients are provided in
Appendix A.
Program Outline
Services
The services offered through Keep It Pumpin Heart Failure Management are based on current
recommendations provided by the AHA and ACC. In order to provide the patient with the highest quality of care
an initial intake session will be performed to obtain pertinent information related to the following: patient story,
medical history, current NYHA classification, medication list, outcome measurements, educational needs, and
functional capacity evaluation. This information will then be used to develop an individualized treatment plan.
The following services will then be performed based on the Keep It Pumpin Membership plan.
Intake Session: Each HF patient will be required to attend an initial session in order to review medical
history and develop an ITP based on HF diagnosis. Intake will also include an exercise assessment
that will determine the patients overall functional capacity. The specific exercise assessment is the SixMinute Walk Test.
Individualized Treatment Plan (ITP): Each HF patient with a Keep It Pumpin membership will have the
opportunity to work with an exercise physiologist/nurse to develop a treatment plan. This treatment plan
will be based off of the current exercise and counseling guidelines provided by the American Heart
Association.
Exercise Sessions: These sessions will consist of an aerobic, resistance and flexibility component.
Each HF patient with the premium and standard membership will have the ability to exercise for 45
minutes with a 5 minute warm-up and 10 minute cool-down consisting of both 5 minutes of resistance
training and 5 minutes of flexibility exercises. The cool down exercises include mainly bodyweight and
dumbbell exercises targeting the four major muscle groups, and In regards to flexibility exercises, the
four major muscle groups will also be targeted. During these sessions each patient will be monitored
through Quinton 4-lead telemetry monitors.
Self-Management Care: The self-management care plan will be individualized based on the HF
patients HF classification and/or implantation of VAD device. This self-management care plan is
modeled after the AHAs recommended behaviors for persons living with HF. The specific components
include medication adherence, symptom management, dietary adherence, exercise, smoking
cessation, and preventative behaviors. This care plan also follows the basis of the patient education
sessions that are provided below. All patients in the premium and standard memberships will be
required to complete a self-management care sheet each session that they attend.
Patient Education: Each HF patient will have the opportunity to attend each education class and receive
handouts regarding the following educational topics. These topics will be taught by either the exercise
physiologist, registered nurse or nurse practitioner. Each education session will be conducted during all
the 30 minute breaks between the five exercise sessions on Wednesdays (refer to hours of operation).
The patient education topics will be implemented on a rotating cycle and all will be available through
login and password on the Keep It Pumpin website. The following educational topics are listed below:
Symptoms of Heart Failure
When to Contact Medical Team
Heart Failure & Low-Sodium
What is Ejection Fraction?
Importance of Fluid Intake
Medication Adherence & Side Effects
Exercise & Heart Failure
Weight Management & Monitoring
End-of-Life Care (NP)

Heart Failure & Follow-Up
Risk Modification
Smoking Cessation
Mechanical Hearts
Exercise & Technology (Wii)
HF & Nutrition
HF & Your Rhythm
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HF Follow-up: Each membership comes with once a month phone follow-up phone calls regarding HF
self-management care. These calls will be performed by either the registered nurse or RCEP using an
American Heart Association approved clinical script that reviews self-management. See Appendix B
Dietitian Session: Each HF patient will have the ability to meet with the dietitian once per month to
discuss more in depth on what foods to eat and avoid, low-sodium, fluid intake, preparation, and
planning ahead. These sessions will take place during the patient education on Wednesdays each
week.

The Keep It Pumpin Heart Failure Management memberships are based on competitive pricing in the
area for direct competition. Our pricing directly relates to the quality, quantity, and availability of services in the
projected area of establishment. According to research, the average disease management program cost
ranges from $70-$200 per month, which is out-of-pocket (8,60). Although Keep It Pumpin memberships prices
are higher than the average, at least 83% of all health plans offer assistance with a HF disease management
program. In order to reduce the out-of-pocket cost of the memberships, Keep It Pumpin will work hard to
establish relationships with insurance companies to determine diagnoses and billing codes. However,
insurance plans can vary, but each case will be handled individually by the patients PCP and rehabilitation
office staff.
The Keep It Pumpin Memberships will be offered on a per month basis. All new patients will be required
to pay an additional start-up and intake fee of $50 at their first visit. The following memberships will be offered
to all HF patients and vary in services offered.
- Premium Membership ($400/month)
o Individualized Treatment Plan (RN/EP)
o Exercise Sessions (3 days/week)
o Self-Management Care (NP/RN)
o Patient Education (RN/EP)
- Standard Membership ($200/month)
o Individualized Treatment Plan (RN/EP)
o Exercise Sessions (1 days/week)
o Self-Management Care (RN)
- Basic Membership ($100/month)
o Individualized Home Treatment Plan (RN/EP)
o Self-Management Care (RN)
Market Analysis
HF is a major health problem with the United States. This disease accounts for nearly 2% of all health
care expenditures, which is estimated at annual cost of $33 billion dollars and is projected to more than double
in cost by 2030 (2,41,46). The combined costs primarily stem from the ever-increasing cost of HF hospital
admissions. Over the past decade hospital admission costs have more than doubled to average $20,000 per
visit. These visits can be reduced significantly if a proper disease management program is implemented and
result in 5.7 fewer hospital stays per patient. This HF disease management program may also help reduce the
25% readmission rate and increase adherence to self-management care. Disease management programs with
a multidisciplinary approach that target HF patients have the greatest potential to produce a significant return
on investment (ROI) and increase life expectancy by more than 1.82 years with an average savings between
$1,800 and $6,000 (16)
HF patients are for the most part of Medicare age, occurring most frequently in those over the age of
60. However, the services that will be provided by Keep It Pumpin will be available to any patients who have a
primary or secondary diagnosis of heart failure regardless of classification. The service areas will be available
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to patients in the Milwaukee area. The availability of the clinic services will be marketed to all the physicians
and hospitalists for possible referrals. Any physicians, doctors offices, case managers and ER staff may initiate
the referrals.
Competitor Analysis
By performing a competitor analysis this allows for us as a program to grow and possibly fill in the gaps
that these general cardiac rehabilitation programs or other heart failure programs may be missing. In regards
to our competition in the Milwaukee and Madison area, no hospital has established a HF specific program. This
supports the establishment of a HF management pilot program such as Keep It Pumpin, due to the only
competition of general cardiac rehabilitation programs.
TABLE 1. Competitor Program Analysis
Competitor
HF Specific Disease Program
Keep It Pumpin
Yes
Aurora St. Lukes Hospital
N/A
Froedtert & Medical College of WI
Yes (Pharmaceutical)
Columbia St. Marys
Yes (General)
Average Cost per Month

$200 - $400
$600
N/A
$600
TABLE 1 analyzes our competitors current HF practices and their cost. For most of these hospitals, the
patients insurances cover most fees leaving a co-pays ranging on average from $0-50 per session. If a
patients insurance does not cover services the average cost per session for these hospitals is $250.
It is important for us to focus on key weaknesses for our competitors, in order to build/ better our
program. One weakness would be limited one on one patient treatment along with generalized patient
education. Both these weaknesses are resolved in our program by having a multidisciplinary team that are
certified HF care providers along with our program being only specific to heart failure of all classes. HF patients
have a specific need in regards to patient education to improve self-management. The quality of life
significantly decreases in these individuals and an understanding of how to self-manage the associated
complications are important. Other weaknesses include the referral process of cardiac rehabilitation. As
previous research shows the participation rate of cardiac rehab is significantly low and continues to be problem
for most programs and could be a significant problem for Keep It Pumpin. Specific opportunities that our
competitors have over our program are minimal and not significant. However, given that our program is specific
to HF patients, expansion and continued growth is minimal and is entirely based on HF diagnoses. Though
there is a lot of overlap with our competitors, patient results will be the vital factor in reasoning for physicians
referring to our program in its place.
Again, after extensive research of the services our immediate competitors of general cardiac
rehabilitation, provided through their websites, both do not offer the same services as proposed. However,
these hospitals due to HF being a newly billable diagnosis these hospitals provide care for newly diagnosed
CHF patients, those with recent hospitalization with CHF as the primary diagnosis or those with frequent CHF
admissions (CMS). Overall these hospitals are not direct competition but could be great referral strategy since
they do not offer the same services.
Given the analysis of the HF population in the surrounding Milwaukee, WI area, the need for an
extensive HF management program is high. To further analyze the potential success of Keep It Pumpin Heart
Failure Management a SWOT analysis using the internal and external format was created.
SWOT Analysis
Internal
Strengths
Certified staff through AAHFN, ACSM, ACC
Evidence-based care and clinical practice
guidelines for heart failure provided by AHA,
ACC, and ACSM
Improved quality of life outcomes through
multidisciplinary approach (QLI)
Community need based on CDC-WI statistics
Affordability through Medicare beneficiaries
Medicare priority to reduce CMS statistics related
to readmissions, complications, mortality, and
quality of life
Weaknesses
New to WI area
Minimal patient referral
Limited space available in CR dept.
Lack of capital and expendable resources
Limited spots available; not enough to
accommodate all heart failure patients
Reimbursement barriers
External
Opportunities
Revenue generation due to memberships and
merchandise
Hospital reputation: Joint Commission
accreditation
Reduced CMS penalty
Hospital savings: Loss prevention of at least
$1,200/patient
Multidisciplinary model of care
Expansion of Keep It Pumpin model to affiliated
hospitals
Threats
Phase II and III Cardiac Rehabilitation
Patient acceptance of exercise-related program
Adherence to management program
Medication therapy
Primary care physician support
In a critical review of the SWOT analysis, a number of strengths and opportunities suggest a solid
benefit to moving forward with our Keep It Pumpin Heart Failure management program. However, significant
weaknesses and threats still remain that may have a significant impact in patient enrollment.
Strengths
Identified strengths of Keep It Pumpin include: having qualified physicians and other health care
providers on staff being trained with a nationally recognized program, along with existence of well accepted
evidence-based care and clinical practice guidelines for heart failure. This program provides a comprehensive
approach to the care of a heart failure patient, unlike the general phase II cardiac rehabilitation programs and
other established heart failure clinics.
Medicare sees reducing heart failure readmissions as a priority among hospitals and this program can
meet the goals suggested by Medicare. This program can improve patient outcomes with a multidisciplinary
approach to heart failure. Given the area prevalence of heart failure within the Milwaukee, WI area, this
program is a must. By having a heart failure management program with not only a multidisciplinary approach
but also a certified team, we have the utmost potential to produce a significant ROI and increase life
expectancy by more than 1.82 years for our patients (2,16). This relates directly to Medicare seeing reducing
heart failure readmission as a priority. These readmission visits can be reduced significantly as well if a proper
heart failure management program is implemented, with successful programs resulting in 5.7 fewer hospital
stays per patient. Medicare also makes this program more affordable for patients with their insurance covering
up to 80% of total costs.
Weaknesses
Weaknesses in the Keep It Pumpin Heart Failure Management Program include: heart failure
management programs being new to Wisconsin and having a lack of budgetary resources. Being new to the
state there are actually no established Heart Failure Management programs, these patients are seen in cardiac
rehabilitation, and in that generic cardiac rehabilitation setting those patients are limited by the extent of their
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disease set by Medicare guidelines. Most hospitals utilize cardiac rehabilitation for their heart failure
management due to the lack of budgetary resources, which should not be the sole reason these patients dont
receive the absolute best care and management techniques for their disease, when there is an established
need and proven progressive results with emerging programs. Additional weaknesses that tie together are that
there is no established referral process; there is minimal patient participation, and limited spots and space
available (15,24). These items are important because they are not only weaknesses for our program but many
cardiac rehabilitation clinics as well.
Opportunities
However, while these may be weaknesses, opportunities emerge from them. The greatest opportunity
for this service will be for those patients who are discharged from the hospital with a heart failure diagnosis.
The discharge planner will be responsible to make the referral and secure an appointment prior to the patients
departure by contacting the clinic. Other opportunities for the Keep It Pumpin program include: revenue
generation, cost avoidance, hospital savings, potential decrease in inappropriate resource utilization, increased
efficiency of physician time, and the growth of a multidisciplinary model of care that will increased the quality of
life for heart failure patients. A specific example of these opportunities was seen two years after enrolling in a
disease management program for congestive heart failure; Florida Medicaid beneficiaries were monitoring their
condition more closely and spending fewer days in the hospital. Beneficiaries were more likely to take
prescription drugs to control their conditions and to receive an annual cholesterol screening. The number of
days spent in the hospital decreased by 39 percent over the two-year period, and health care expenditures for
the 2,500 beneficiaries decreased by 16 percent, a savings of $4.4 million after program costs (23,56).
Threats
Overall, all our threats to the program can be generalized into one large category of patients utilizing
other means to manage their disease. Whether that is through pharmaceutical or cardiac rehabilitation. Along
with physicians referring to these other alternatives for disease management rather than our heart failure
specific program.
Strategies to Overcome Weaknesses
After thorough review of each element of the SWOT, the developing strategy will concentrate on the
opportunities that emerge from our weaknesses. Items not included are the strengths and weaknesses that are
common to all CR and HF programs in direct competition, and items that may not be approachable as part of
this business plan. That being said there are huge ranges of hospitals developing and or developing additional
services for heart failure or in similar fields. Most of the competition is still in the initial phases and though some
have done more development, we think we can do better. Our solution will be simple to implement and will
have incremental benefits for patients and hospital care. Through our model of utilizing a multidisciplinary team
to address the complications of heart failure, reduction in hospital losses and readmissions can be reduced.
In order to do this we have to have a presence in the market, which, requires that our services be
positioned versus competing services. Positioning depends upon the strengths and weaknesses of the
program, as seen in the SWOT analysis, and the issues in the external environment. For our proposed heart
failure clinic, the appropriate positioning strategy is cost leadership, which uses services that are simple to
produce. The market entry strategy appropriate for this plan is internal venture strategy, which is the
establishment of an independent entity within an organization, i.e. an established hospital, to develop products
or services. This strategy allows the use of existing resources, which is how our heart failure clinic will be
designed and removing of multiple weaknesses stated in our SWOT analysis. In order to gain success, the
support of the physicians and staff to the program are again critical and can help reduce weaknesses and
threats with referrals and support to our program.
Despite significant advances in treatment and prevention, the total number of HF patients has remained
stable over time, with there being more than 550,000 new cases diagnosed annually. However, the HFvulnerable population will grow as the senior population continues to increase greatly. Therefore, even if care
becomes better and more efficient, HF prevalence will likely continue to increase. Then breaking those
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numbers down further for the Milwaukee area, with HF being 17.4 per 1000 people being hospitalized (31).
These patients are then usually referred to home care or more currently general cardiac rehabilitation post
discharge. The services that these hospitals currently offer are limited and sometimes lacking due to visit
restrictions. It is the hope that our proposed heart failure clinic will bridge the gap in care in the outpatient
setting.
Business Model
Hours of Operation
Keep It Pumpin Heart Failure management will operate out of the cardiac rehabilitation department of
the attending Milwaukee or Madison hospital on the following weekdays: Monday, Wednesday, and Friday.
Hours of operation for the heart failure clinic will be 8:00 AM to 5:00 PM. During these days of operation, five
exercise sessions with a capacity of 15 patients per session, allowing a 5:1 patient per clinician ratio, will be
conducted. The layout of the hours of operation is displayed in TABLE 2. In regards to responsibilities
throughout the day-to-day operations of the facility, the RCEP, CEP, and one RN will be on the floor at all times
during the exercise sessions. The additional RN will be in charge of office work at that designated time. This
office work includes: creation of ITP, entering outcome data received from patients, and making the follow-up
phone calls to patients.
TABLE 2. Keep It Pumpin Hours of Operation
Hours
Monday
Wednesday
Friday
8:00 - 9:00 AM
Exercise Session
Exercise Session
Exercise Session
9:00 - 9:30 AM
Phone Follow-Up
New Intakes
Patient Education
New Intakes
Phone Follow-Up
New Intakes
9:30 - 10:30 AM
Exercise Session
Exercise Session
Exercise Session
10:30 - 11:00 AM
Phone Follow-Up
Patient Education
Phone Follow-Up
11:00 - 12:00 PM
Exercise Session
Exercise Session
Exercise Session
12:00 - 12:30 PM
Phone Follow-Up
Patient Education
Phone Follow-Up
12:30 - 14:00 PM
Lunch Hour/Additional Office Work
14:00 - 15:00 PM
Exercise Session
Exercise Session
Exercise Session
15:00 - 16:00 PM
Phone Follow-Up
New Intakes
Patient Education
Patient Education
Phone Follow-Up
New Intakes
16:00 - 17:00 PM
Exercise Session
Exercise Session
Exercise Session
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Workforce
In order to create the most beneficial environment for HF patients a multidisciplinary team is needed.
This team will provide the HF patients with the most specialized care. In order to provide the best quality of
care to our HF patients, the program will be directed by a current Advanced HF and Transplant Cardiologist
employed by the hospital. According to recent research on the most effective HF disease management
programs, the greatest outcomes come from a program directed by a Cardiologist, then followed by a Nurse
Practitioner. The supervision of the program will be performed by a current Nurse Practitioner that specializes
in HF care. All other operational duties will be conducted by the floor staff, which include the RNs and EPs.
These duties include, but are not limited to: floor supervision, exercise prescription, education sessions, client
intakes, and follow-up phone calls. A hospital employed dietician will be available 4 hours/week to meet with
HF patients in regards to a proper diet that benefits the HF patient. The workforce is provided in Table # along
with their specific FTE.
TABLE 3. Keep It Pumpin Heart Failure Management Workforce
Employees
Cardiologist
Nurse Practitioner
Registered Nurse
Registered Nurse
RCEP
Clinical CEP
Dietician
FTE
0.15
0.75
0.75
0.50
0.75
0.75
0.10
Total Salaries:
Yearly Salary
$
57,750.00
$
75,000.00
$
44,250.00
$
27,650.00
$
37,500.00
$
30,000.00
$
5,700.00
$ 277,850.00
Job Descriptions
See Appendix C
Workforce Flow Chart
Medical Director
Cardiologist
Nurse Practitioner
RCEP
Clinical Exercise
Physiologist
Registered Nurse
Dietitian
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Marketing Strategies
Strategy One: Discharge Referral/PCP Referral
Awareness of our HF program for those that are hospitalized is a key aspect to the success of Keep It
Pumpin. An EP prior to discharge from the hospital will target each patient hospitalized for a HF code. This will
involve the use of a brochure, brief explanation of what the program can do for them, and the available
membership tiers. For those individuals that have a lesser degree HF diagnosis or are currently seeing their
PCP for management, brochures will be available throughout the hospital system, i.e. patient rooms, waiting
rooms, etc. Business specific brochures can be created at professional websites like PsPrint, where you up
load your design or chose one of theirs; 250 brochures, 8.5x11, full color on both sides, cost approximately
$173.88. This and its cost will be established through the community networking expense.
Strategy Two: Create local awareness.
Gaining coverage in local papers, trade magazines and websites can greatly increase our name recognition
and educate people about our business. This will be done by researching publications and writers that cover
our industry and from the community networking cost of the first year.
Cost
Local Newspaper For a single insertion in the business section for the week at a local
newspaper (Milwaukee Journal Sentinel) cost ranges from $93-$156, with a minimum ad size of
3 inches.
Website Creating a website for our program can range greatly, average costs in 2014 ranged
from $6,000 to $20,000 and that covers the websites design, development, and launch. After
that is said and done maintenance costs need to be incorporated and those on average cost
$250/month. With this maintenance plan though the designer/developer usually includes
additional work such as creating new images, adding new content, maintaining social media or
newsletters, etc.
Once we have a grasp on the writers we may want to reach, we will craft a pitch around our business
that will grab their interest. For example, Entrepreneurs and small business owners can also subscribe to Help
a Reporter Out. This free service provides queries for upcoming articles -- allowing one to contact the writer
directly.
Strategy Three: Utilize social media.
Along with creating local awareness through advertising using social media pays for itself, is easy to get
started, and offers a massive network of potential customers. To start we need to identify the social channels
that reach our customers best including Facebook, Twitter, Pinterest, Instagram, and LinkedIn. The goal
would be to provide our followers with something thats useful, interesting and shareable. If we would like to
outsource our social media marketing it can cost on average $4,000-$7,000 per month for two social networks.
But this includes all upkeep and maintenance. Again, like many of our marketing strategies will be funded by
the community networking costs.
Strategy Four: Customer engagement with email marketing
According to a recent survey conducted by Ascend2, email is the most effective digital marketing tactic,
the one that delivers the best ROI and the least difficult to execute. Utilizing this we could start a customer
newsletter that offers timely information about our business, special promotions or an inside look at the
company. This will help build a community with our customers, and it will keep our business on their minds.
This also can be done by using free services, such as MailChimp, which allows small-business owners to send
marketing emails, automated messages and targeted campaigns to customers.
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Cost
E-Newsletters: the cost in developing this E-newsletter will depend on the number of articles
that we want included in the article. On average according to comapnynewsletter.com, if we
write the articles and the website edits for 6-8 articles will cost on average $695-$927.
As one can imagine it costs considerably less to keep a customer than to win a new one. In fact if one
is not communicating with their customer database at least every four to six weeks, opportunities are being
missed to grow ones business. Using a combination of sales and marketing tactics to stay in touch, such as
alternating referral calls with e-mail and postal mail. By us making a habit of periodically using our marketing
communications to ask for referrals. For example by utilizing e-mail and e-newsletters we could send success
stories, and ask the recipients to forward it to others who would like to achieve similar results.
Strategy Five: Tempt customers with incentives
Customers who've had positive experiences with a company's services in the past will happily return.
This can be done through a loyalty program which can take many forms, from coupons, vouchers, a
percentage back on their total spend or rebate, additional product, to priority to supplies, products, and
services. Or could utilize a points system. But attracting new customers requires making a special offer. For
example our business could offer a free or discounted merchandise. These incentives could also be offered to
the customer who brings in more patients. For example if a previous client brings in an additional client, they
will be rewarded through the loyalty program. To develop a loyalty program it is fairly simple if we outsource it
to one of many businesses like Belly for Business.
For a basic package Belly for Business develops and launches your loyalty program, customer insights,
mobile exposure, and 12 campaigns for $129 per month. If we want to use their additional sources, which tie
into our other marketing strategies, these include their Core and Complete packages, costing $159 or $209.
The core package includes, merchant mobile app, marketing automation, social media marketing, customer
acquisition, and 48 campaigns. Upgrading one more package includes free installation, prioritized customer
support, premium iPad stand, and unlimited campaigns.
Strategy Six: Merchandise
By offering merchandise to patients it will provide a secondary source of marketing. This merchandise
includes t-shirts, sweatshirts, water bottles, etc. All merchandise and educational packages will be made
available on the company website.
TABLE 4. Keep It Pumpin Merchandise
Merchandise
T-Shirt
Sweatshirt
Water Bottle
Pedometer With Logo
Patient Education Videos
Package Deal (Pt Ed) Videos
Self-Management and Care Package
Price
$24.99
$39.99
$19.99
$4.99
$2.99
$29.99
Additional Forms of Revenue

In order to maximize Keep It Pumpins revenue and further our advertising and marketing strategies,
additional revenue streams will be available. These additional revenue streams are based on the services that
Keep It Pumpin Heart Failure Management will be providing. The multiple patient education topics will be
available on DVD, either individually or in a package deal. To assist the HF patient with their self-management
care a self-management care package will be available to all patients. This care package includes: water
bottle, weight scale, t-shirt, pedometer, and resistance bands.
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Patient Outcome Measurements

Measuring outcomes is recognized as an essential component in the evaluation of the effectiveness of
heart failure management and similar cardiac rehabilitation programs. An outcome is the end result of a
process. In programs like cardiac rehabilitation, it is the measure of a patients progress toward a defined goal.
Outcomes are also data collected to demonstrate the efficacy of a programs procedures (1). This will be an
important aspect of our heart failure management program in order to justify the value of our programs
services both clinically and financially. Outcome measures will be logged in the CMS database and also the
AACVPR website. Keep It Pumpin Heart Failure Management will use the following outcome measurement
tools to assess and track the effectiveness of the Keep It Pumpin program:
Quality of Life Survey (All components)
Ferrans and Powers Quality of Life Index (QLI)http://qli.org.uic.edu/questionaires/pdf/cardiacversionIV/Cardiac4english.pdf (actual survey). The
QLI was developed by Carol Estwing Ferrans and Marjorie Powers in 1984 to measure quality
of life in terms of satisfaction with life. The QLI measures both satisfaction and importance
regarding various aspects of life. Importance ratings are used to weight satisfaction responses,
so that scores reflect satisfaction with the aspects of life that are valued by the individual. The
QLI produces five scores for quality of life overall and in four domains (health and functioning,
psychological/spiritual domain, social and economic domain, and family). A few particular
studies done in 2000 and 2004 by Scott et al., based on the validity of the QLI for heart failure
patients showed an alpha of .89-.96 for the Internal Consistency Reliability of the Ferrans and
Powers QLI (50). The cardiac version of the QLI will be used for patient outcome measures.
Functional Survey
Duke Activity Status Index (DASI) -http://www.phsoregon.org/newsletters/ecardiovascularbeat/assets/downloads/Duke-Activity-Status-Index.pdf (actual survey). The DASI is a
questionnaire to assess the functional capacity. The DASI has been used mainly to evaluate
patients with cardiovascular diseases, such as coronary artery disease, heart failure, myocardial
ischemia and infarction. One study done in 2015 by Fan et al. on the use of the DASI on HF
patients showed an Internal consistency reliability of the DASI was high (Cronbach's
alpha=0.86). Showing that this instrument can be used to evaluate functional status and
enhance the health care providers understanding of functional status related to daily living from
the patient perspective (22).
Psychosocial Survey
The Patient Health Questionnaire (PHQ-9) -http://www.cqaimh.org/pdf/tool_phq9.pdf (actual

survey). The PHQ is a self-administered version of the PRIME-MD diagnostic instrument for
common mental disorders. Depression in patients with heart failure commonly goes
undiagnosed and untreated. The PHQ-9 is a simple, valid measure of depressive symptoms
that may facilitate clinical assessment. Hammash et al. has also confirmed its validated in
patients with heart failure, alpha of .83 for internal consistency reliability (28).
Nutritional Survey
Rate your plate (RYP) -https://www.brown.edu/academics/public-health/centers/communityhealth-promotion/sites/brown.edu.academics.public-health.centers.community-healthpromotion/files/uploads/RYP%20Heart%202010_0.pdf (actual survey). RYP is a simplified foodfrequency questionnaire consisting of questions focusing on foods contributing the most fat,
16
saturated fat, and cholesterol to the American diet. This tool was developed by the Pawtucket
Heart Health Program in the 80s.
Functional Measures
In addition to these tools, functional capacity based outcomes will be determined through using
the 6MWT protocol made available through the American Thoracic Society (ATS). This protocol
has been proven to be a reliable tool to assess the prognosis of HF patients. It is a strong
protocol that has been suggested as safe, effective, and also an inexpensive alternative to
cardiopulmonary exercise testing. Each HF patient will have a goal of achieving 300 meters or
988 feet for the 6MWT. A distance of less than the 300 meters has shown an increase in
mortality and poorer outcomes in the next 6 months (6). The 6MWT will assist in the
effectiveness of the quality of life scores. According to Myers et al (2006), quality of life scores
show a positive correlation in the distance achieved through the 6MWT, supporting the use of
both of these methods to assess outcomes of the Keep It Pumpin program.
TABLE 5. Program Outcome Measurements

Measurement
Program
Readmission Rate
ED Visits
Patient Satisfaction
Patient
LVEF
QLI
Duke Activity Status Index
PHQ-9
Rate Your Plate
6MWT Distance
Intervention
Goal
Self-Management
Self-Management
< 20% of patients

< 20% of patients
Survey
Exercise
LVEF of 5%
score of 2 points
Dietitian Sessions
Exercise
Avg. score of 50
> 300 meters
In regards to exercise performance and progression, as stated before, the initial intake will require the
performance of a 6MWT to determine each HF patients baseline aerobic fitness. This protocol has been
proven to be a reliable tool to assess the prognosis of HF patients. It is a strong protocol that has been
suggested as safe, effective, and an inexpensive alternative to cardiopulmonary exercise testing. Each HF
patient will have a goal of achieving 300 meters or 988 feet for the 6MWT. A distance of less than the 300
meters has shown an increase in mortality and poorer outcomes in the next 6 months. The 6MWT will assist in
the effectiveness of the quality of life scores. According to Myers et al (2006), quality of life scores show a
positive correlation in the distance achieved through the 6MWT, supporting the use of both of these methods to
assess outcomes of the Keep It Pumpin program.
Over the past years, patient satisfaction surveys have gained increasing attention as meaningful and
essential sources of information for identifying gaps and developing an effective action plan for quality
improvement in healthcare organizations (4,34). Patient satisfaction is defined as patient-reported outcome
measure while the structures and processes of care can be measured by patient-reported experiences (4). In
order to improve Keep It Pumpin Heart Failure Management quality and continue to improve care, our clinic will
use the following satisfaction dimensions:
-
Technical
Interpersonal
Social
Moral
17
Employee Satisfaction & Benefits

At Keep It Pumpin Heart Failure Management employees are held at a high standard to provide the
highest quality of care to our patients. To care for patients with skill and compassion, our employees need to be
engaged, trained, and motivated. Employee engagement surveys make sure physicians and staff have
everything they need to put patients first. Studies have shown that more than half of healthcare providers
measure employee satisfaction as part of their effort to offer great care (10). This is due to the strong
correlation between employee satisfaction and patient satisfaction (45). Employee satisfaction is important to
the performance and quality of care that our patients receive. In order to increase patient outcomes and
satisfaction employees must first be motivated and productive (10). This can be achieved through offering a
variety of employee benefits. If we do not measure employee engagement, we could be overlooking a key
element that impacts patient satisfaction and health outcomes. In order to produce these desired outcomes of
the program, employee satisfaction and benefits are necessary.
Employee Orientation
All employees will attend an employee orientation consisting of tour of facility, job duties, teambuilding skills, and luncheon.
Satisfaction Survey
All employees will complete a satisfaction survey every six months to determine effectiveness of
program and make notice of any concerns regarding strengths, weaknesses, and gaps in the
Keep It Pumpin program. The provided satisfaction survey link it listed below:
http://www.pathwaysforpeople.org/stuff/contentmgr/files/c780b631269588db8c900a7477988699
/miscdocs/employee_survey.pdf
Employee Development
All employees will be required to attend at least two continuing education courses (CECs) each
year to further their educational and employee growth. Specifically, these courses will focus on
HF best practice and advancements in treatment for HF patients.
Health Insurance
Offered to all employees working above .50 FTE or at least 20 hours per week. These
employees include: Nurse Practitioner, Registered Nurse, and Registered Clinical Exercise
Physiologist. Health insurance benefit is effective the first of the month, following date of hire
and includes medical, dental, and vision. Percent of premiums paid by Keep It Pumpin Heart
Failure Management are based on employee FTE.
Retirement 401(k)
Offered to all employees working above .50 FTE or at least 20 hours per week. These
employees include: Nurse Practitioner, Registered Nurse, and Registered Clinical Exercise
Physiologist.
Paid-Time-Off
Offered to all full-time and part-time employees. Part-time employees earn it at a rate equal to
50 percent of full-time employees for months they work at least 100 hours or 25 hours/week.
Must be scheduled at least 30 days in advance and be approved by Nurse Practitioner. A
maximum of 32 hours of PTO can be carried over to the next calendar year.
Paid Vacation
18
Offered to full-time employees at two weeks per year. All vacation requests must be made at
least 90 days in advance.
Holiday Pay
Offered to all full-time and part-time employees who are not during their introductory 90-day
period. The following holidays are recognized by Keep It Pumpin Heart Failure Management:
New Years Day
Memorial Day
Labor Day
Thanksgiving Day
Christmas Day
If a holiday occurs on a scheduled PTO, the employee is permitted to take an
extra day of PTO.
Overtime
Offered to all full-time and part-time employees. All hours worked after 40 hours in a workweek
are paid at one and one half times employees regular rate of pay.
Sick-Leave
Offered to both fulltime and part-time employees. All full-time employees accrue sick leave from
the date of hire, for a total of 10 days per year. All part-time employees accrue sick leave from
the date of hire, in a prorated amount using the full-time total of 10 days per year and the
average number of ours the part-time employee works per week.
May accrue a maximum of 120 hours
Sick leave may be used for an employees personal illness, well-care and medical and
dental appointments. Sick leave alos may be used for illness and well-care of a member of
an employees immediate family (including the employees spouse, children, mother and
father)
An employee who has a sick leave absence in excess of three consecutive work days must
present medical documentation for the absence
Annual Party/Outing
Keep It Pumpin Heart Failure Management sponsors at least one annual employee gettogether. If employees are scheduled to work the day of the event or time of the event Keep It
Pumpin Heart Failure Management will pay for the hours you are at the event.
Employee Quality
To ensure that all Keep It Pumpin employees have the knowledge to relay to all their patients,
competency testing will be mandatory on a monthly basis per competency. All competencies are based off of
program requirements based on the components of heart failure programs and the established core
competencies identified Amercian Association of Cardiovascular and Pulmonary Rehabilitation. All
competencies are listed below with short descriptions:
Heart Failure diagnoses: all diagnosable HF codes with brief descriptions

Heart Failure symptoms: associated symptoms of HF
Heart Failure and self-care: components of self-care management
Heart Failure medications: associated medications for HF and side effects
Nutrition for HF: proper diet including salt intake and fluid intake
Exercise for HF: proper exercise modalities and intensities
19
Risk modification: associated risks/complications of heart failure

Ventricular Assistive Devices: proper usage
All employees of Keep It Pumpin Heart Failure Management will have 1-on-1 performance
assessments completed every six months. These assessments will review the employees overall
performance, employee satisfaction through completed survey, program effectiveness, and personal employee
growth goals.
Technology
Cardiac rehabilitation is a secondary prevention crucial component that has been developed and
implemented in the past decades due to the scientific evidence of its multiple benefits. Given this, Keep It
Pumpin will work directly with a Cardiac Rehabilitation Program and utilize the general technology they already
have in place such as laptops, iPads, monitoring systems, Wii gaming systems, email, fax, telephone, etc. In
order to accommodate the increased number of patients an additional fax and phone number will be
established for all HF operations within the office of the program manager. In regards to computer programs
involving patient records and telemetry, the program will use EPIC and Quinton, respectively. These programs
are already established within the cardiac rehabilitation department and will easily accommodate the additional
170 patients the first year and 200 patients the following year.
Legal
As a potential program within an established hospital and supporting healthcare system, all legal
matters will be handled by the attorneys appointed by the hospital. These legal matters include, but are not
limited to; claims regarding patient care, medical staff, ethics issues, professional liability, general liability
claims, and risk management issues. The mission of the hospitals legal department in the relation to the Keep
It Pumpin Heart Failure Management is to protect and preserve the legal, ethical, and financial integrity and
reputation of the Hospital. To further prevent and lessen the occurrence of any litigation sought by the patients
of Keep It Pumpin Heart Failure Management, a risk management plan will be put in place.
The risk management plan is designed to support the mission and values of Keep It Pumpin Heart
Failure Management. This plan is the framework to prevent the above stated legal claims, as it pertains to
clinical risk and patient safety within the program. The risk management plan is administered through the risk
manager of the department (Nurse Practitioner). This risk manager will interface with all administrative staff
responsible for legal matters. Key policies and procedures of the risk management plan are listed below (8):
Joint Commission program accreditation

Documentation of all outcome measures stated in patient outcomes section
o AACVPR outcomes registry
Staff credentials and certifications: ACSM, AAHFN, ABIM
BLS/ACLS certifications
Employee handbook: policies and procedures
Workplace environment
o Title VII
o Sexaul harrassment
o Occupational Safety and Health Administration
Employee professional liability insurance: $250/year
Establishment of employee patient safety/risk management committee
5:1 Patient/Staff ratio maintained at all times
Staff participation in educational programs on patient safety and risk management
Staff competencies (as listed in the employee quality section)
Defenses of negligence
o Informed Consent
o Release of Liability
20
Orientation to program and equipment
Standardized preventive screening (i.e. initial intake)
Safety notices are clearly posted on or near necessary equipment
Unsafe equipment marked with standardized paper. All unsafe/dysfunctional equipment will be reported
to maintenance department for repairs
Documentation of daily equipment checks (crash cart, exercise machines, etc.)
Facility and equipment arrangement follows AACVPR guidelines
Written documentation of emergency procedures including standardized procedures of medical
emergencies
Mock emergency protocols (employee rotation)
Recording of all adverse events, near misses, and unsafe conditions
Statistical trend reports of adverse events, claims, and effectiveness of risk management program
Recording of patient satisfaction and complaints
Patient and family communication of program progression
o
Capital & Expendable Expenses

Based on the program being set within an original cardiac rehabilitation facility, the need for many
capital expenses can be significantly reduced. The first capital investment would be to obtain a CareFusion
Vmax cart to assess the cardiopulmonary function of each of our patients to determine the extent of their heart
failure given that loss of heart failure can lead to significant pulmonary complications. Due to Keep It Pumpin
establishing itself within a pre-existing cardiac rehabilitation program additional monitors will be needed along
with replacement wires. A HF patient registry will be made to track all patients throughout the program to
document related outcomes and progress. In regards to the enhanced external counterpulsation machine, this
will be used for all heart failure patients that also meet the angina class of three or four provided by the
Canadian Cardiovascular Society. This is due to the fact that most HF patients, specifically 70-80%, suffer from
ischemic heart disease as well. This therapy is cost-effective compared to the normal invasive procedure of
coronary angioplasty and with EECP in combination with pharmacological therapy, exercise duration is
improved by 60 seconds. According to recent studies performed by the American College of Cardiology, 80%
of all HF patients see benefits when participating in EECP therapy (ACC). Once the program is established
both RNs will be required to obtain their HF training certificate within three months of hire. The community
network expense will be used to promote the program throughout the affiliated health systems and also
promote the continuity of HF management throughout the Madison or Milwaukee area.
TABLE 6. Capital Expenses (Plan A)
Equipment
CareFusion Vmax
Vascular Doppler
Q-Tel RMS Monitor
Q-Tel RMS Monitor 4-Wire Leads
CHF Patient Registry Set-up
Enhanced External Counterpulsation Machine
Heart Failure Training/Certification (Nurse)
Community Networks
$
$
$
$
$
$
$
$
Cost per Item

40,000.00
600.00
620.00
115.00
3,000.00
25,000.00
400.00
5,000.00
# of items
1
2
10
20
1
1
1
1
Total Costs:
$
$
$
$
$
$
$
$
$
Total Cost
40,000.00
1,200.00
6,200.00
2,300.00
3,000.00
25,000.00
400.00
5,000.00
83,100.00
A second capital expense category was created in order to analyze the possible savings if the attending
hospital has additional unused equipment such as the Quinton telemetry monitors and additional lead wires.
Other avoided expenses include the CareFusion Vmax and the EECP machine, which significantly decreases
the total start-up costs for the program.
21
22
TABLE 7. Capital Expenses (Plan B)

Equipment
Vascular Doppler
CHF Patient Registry Set-up
Heart Failure Training/Certification (Nurse)
Cost per Item

$
600.00
$
3,000.00
$
400.00
# of items
2
1
1
Total Cost
$
1,200.00
$
3,000.00
$
400.00
Total Costs:
4,600.00
The expendable expenses are purely based on the addition of at least 120 patients that will be using
the exercise facility at varying degrees; either 3 days/week or 1 day/week. These include a greater amount of
electrodes and alcohol wipes based on the total needed per month to accommodate these patients. The
patient education resources are based on the target goal of 170 clients, at $10 per packet.
TABLE 8: Expendable Expenses (Plan A/B)
Item
Gloves
Gauze Pads
Nu-Prep
Glucose Tablets
Blood Glucose Test Strips
Electrodes
Alcohol Wipes
Patient Education Resources & Dissemination
# of items
32 boxes
3 boxes
170 packets
$
$
$
$
$
$
$
$
Cost
2,000.00
1,100.00
210.00
450.00
110.00
4,300.00
130.00
1,700.00
Total Costs:
6,130.00
Break-Even Analysis
The break-even analysis for Keep It Pumpin Heart Failure Management provides insight to the
effectiveness of the program based on possible revenue with the sale of at least 170 memberships for the first
year of operation. The costs row includes the capital, expendable, and operational costs for the first year of
operation as well. The total revenue according to a projected patient volume of 170 patients is $476,500 and
the total costs is $388,680.00. According to this analysis Keep It Pumpin will more than break even with a
projected profit of $87,820.00 through membership fees for PLAN A. If the attending hospital is able to
accommodate the program needs through used equipment, the potential profit for PLAN B is $157,420.00.
TABLE 9: Break-Even Analysis (PLAN A)
REVENUE (Per Year)
COSTS (Per Year)
Results:
Total
$476,500.00
Total
$388,680.00
$87,820.00
Results:
Total
$476,500.00
Total
$319,080.00
$157,420.00
TABLE 10: Break-Even Analysis (PLAN B)

REVENUE (Per Year)
COSTS (Per Year)
23
Strategy & Implementation

In order to have sufficient time to completely plan the specifics of this proposal, and to not compete with
the hospitals other endeavors. The proposed implementation date is January 2017 (14,57).
24
TABLE 11: Implementation Plan
When
What
Services & Plan
Meeting with Medical Director
Financing Budget
January 2017
(Every 2 Weeks)
February 2017
(Every 2 Weeks)
March 2017
(Meet Weekly)
Parking Lot
Capital/Expendables
Needs/Equipment
Workforce
Sales/Revenue Potential
Memberships (Bell
Curve)
Merchandise
Policy and Procedures
Job Descriptions
HIPPA
EPIC
Purchasing
Equipment
Appointment of Staff Hiring
Recruitment/Referral Process
Brochures
Direct Referral
Community Networking/Physician
Support Sponsors
Staff Certifications
AAHFN
RCEP
ACLS
o (Re-Certification
every 2 years)
Finalization of Finance & Registration
Go Live!
Staff Satisfaction & Competencies
Site Updates/Meeting with IT
Who
Sponsors & All Members
Sponsors, All Members, Appointee from
Finance
Sponsors, Lead NP, Appointee from
Finance
All Members

Sponsors, Lead NP, Board Member
Representative, Donor Representative
Sponsors, All Members, Quality

Department

All Members
Sponsors & IT
25
Financial Program Assistance

Grants
As a program that is identified as having the ultimate goal of maintaining a chronic disease, Keep It
Pumpin Heart Failure is labeled as a chronic disease management program. Given this identification, the
possibility of financial assistance to establish the program is feasible. This financial assistance is achieved
through the application of grants through the American Heart Association and Centers for Disease Control. The
purpose of the heart failure initiative is to stimulate innovative research to address inadequately answered
questions about disease management in clinical practice for chronic heart failure (HF). Because the nature and
scope of the proposed research will vary from application to application, it is anticipated that the size and
duration of each award will also vary. The total amount awarded and the number of awards will depend upon
the mechanism numbers, quality, duration, and costs of the applications received. The American Heart
Association also advocates for federal funding that helps the Centers for Disease Control and Prevention
(CDC) sustain efforts to reduce and prevent the prevalence of CVD.
Financial Projection
Pro Forma: Plan A (Minimum of 170 patients)
SEE APPENDIX D
Pro Forma: Plan B (Minimum of 170 patients)

See Appendix E
Findings/Recommendations
Proposed Findings
By implanting this program the attending hospital can expect a ROI within the first year. If the program
uses either plan for implantation, the investor is guaranteed to have their money returned in the first year of
business. Our success is based upon the referral rate from cardiologists; therefore, the need for marketing this
new program is essential to the success of the program. The likelihood of having a successful heart failure
program in the selected area is very probable and due to the lack of established programs, not only in
Wisconsin but the United States. This multidisciplinary approach has the ability to spread to each region of the
United States and ultimately reduce 1) CMS penalties through readmissions, 2) decrease the amount of
revenue lost per hospital, 3) increase hospital revenue, and 4) increase these patients quality of life.
Conclusion
Again, the incidence of heart failure is increasing. It is therefore binding on healthcare providers to
evaluate their heart failure practices and to incorporate the most current knowledge of the pathophysiology,
assessment, and treatment modalities for heart failure into their patient care. Critical to the success of heart
failure management is the discharge planning process and follow-up in the outpatient setting, which is where
our program fits into Cardiac Rehabilitation services.
26
Appendix
Appendix A:
Heart Failure ICD-9 Codes
Appendix B:
Heart Failure Phone Call Script (American Heart Association: Target HF)
Appendix C:
Keep It Pumpin Job Descriptions
Appendix D:
Pro Forma A
Appendix E:
Pro Forma B
Appendix F:
References
27
Appendix A
Code
402.0
1
402.11
402.9
1
404.0
1
404.0
3
404.11
404.1
3
404.9
1
404.9
3
428.0
428.1
428.2
0
428.2
1
428.2
2
428.2
3
428.3
0
428.3
1
428.3
2
428.3
3
428.4
0
428.4
1
428.4
2
428.4
3
428.9
ICD-9 Description
Hypertensive heart disease, malignant, with heart failure
Hypertensive heart disease, benign, with heart failure
Hypertensive heart disease, unspecified, with heart failure
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, benign, with heart failure and
with chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, benign, with heart failure and
chronic kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease stage I through stage IV, or unspecified
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and chronic kidney disease stage V or end stage renal disease
Congestive heart failure, unspecified
Left heart failure
Unspecified systolic heart failure
Acute systolic heart failure
Chronic systolic heart failure
Acute on chronic systolic heart failure
Unspecified diastolic heart failure
Acute diastolic heart failure
Chronic diastolic heart failure
Acute on chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Acute combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acute on chronic combined systolic and diastolic heart failure
Heart failure, unspecified
Description
MAL HYPERT HRT
DIS W HF
BENIGN HYP HT DIS
W HF
HYP HT DIS NOS W
HT FAIL
MAL HYP HT/KD I-IV
W HF
MAL HYP HT/KD STG
VWH
BEN HYP HT/KD I-IV
W HF
BEN HYP HT/KD STG
V W HF
HYP HT/KD NOS I-IV
W HF
HYP HT/KD NOS ST V
W HF
CHF NOS
LEFT HEART FAILURE
SYSTOLIC HRT
FAILURE NOS
AC SYSTOLIC HRT
FAILURE
CHR SYSTOLIC HRT
FAILURE
AC ON CHR SYST
HRT FAIL
DIASTOLC HRT
FAILURE NOS
AC DIASTOLIC HRT
FAILURE
CHR DIASTOLIC HRT
FAIL
AC ON CHR DIAST
HRT FAIL
SYST/DIAST HRT FAIL
NOS
AC SYST/DIASTOL
HRT FAIL
CHR SYST/DIASTL
HRT FAIL
AC/CHR SYST/DIA
HRT FAIL
HEART FAILURE NOS
GENERAL INFORMATION
28
Discharge date:
(mm/dd/yyyy)
Appendix
B
Patient name:
Date of birth:
(mm/dd/yyyy)
Primary care physician:
Cardiologist:
Heart failure diagnosis:
Homecare?
YES
Appendix
C
NO
Labs ordered/done prior to first

follow-up call or appointment?
YES
NO
Date:
(mm/dd/yyyy)
PATIENT EDUCATION
INTRODUCTION: My name is _______________________. I am calling from [INSERT
HOSPITAL NAME]. I am doing a follow-up courtesy call to see how you are doing.
Weight Monitoring
Do you have a scale at home that
you can use to weigh yourself?
YES
NO
If no: Comments__________________________
[If patient answered no, advised the

patient to buy a scale]
YES
NO
[If patient answered yes to having a

scale] Can you see the numbers on
the scale?
YES
NO
Have you been weighing yourself

daily?
YES
NO
Dry weight (at home,1st day after discharge)

Did you take your dry weight 1 day
after discharge?
YES
NO
Do you have a weight diary?
YES
NO
If no, was the patient

provided with a weight
calendar this year
Do you understand how and when to
check your weight?
YES
NO
YES
NO
[Tell patient that he/she should

check weight every AM, after first
void, prior to PO intake; with same
amount of clothing on]
Do you understand the importance
of measuring and recording your
daily weights?
YES
NO
29
Cardiologist
Job Summary
Diagnose illnesses and prescribe and administer treatment for patients. Cardiologist also examines patients,
obtain medical histories, and order, preform, and interpret diagnostic tests. Cardiologists job also includes the
counsel of patients on diet, hygiene, and preventative health care.
Responsibilities
Provide treatment to patients suffering from heart problems
Should be updated on the latest heart procedures and studies as new breakthroughs are made in this
field on a daily basis as it is one most researched human organ
Design a healthy diet chart for the patient as diet affects the heart the most
Design a good exercise regimen exercise to help in quick recovery and it makes the heart stronger
There are various illnesses of the heart so the cardiologist has to be updated on developments in each
Maintain detailed reports on each patient and also a report on their progress
Coordinate with any other specialist the patient might be seeing
Give medicines that are compatible with the other medicines the patient is taking
Advice patients on any alternative treatment they might be seeking
Help the patient to fully recover from their illness and have the patient follow up even after they are
okay as it post recovery treatment is also important
Education and Qualifications/Skills
Doctor of Medicine (M.D.)
2-3 year residency; fellowship
Three-year specialized training in cardiology/heart failure
Board certified in Cardiovascular Disease and Board Eligible in Advanced Heart Failure and Transplant
Cardiology.
The ideal candidate should have experience in mechanical circulatory support and an interest in clinical
research and teaching.
Nurse Practitioner
Job Summary
Provides direct diagnostic, therapeutic and preventive health care services in collaboration with the Medical
Director. NP will provide specialized care to the heart failure patient and serves as an advisor, resource,
preceptor and leader for other members of the patient care team.
Responsibilities
Coordinates care for patients in the Cardiology clinics to ensure that the care is timely, appropriate, of
high quality and cost effective.
Provides professional assessment, coordination and planning of multiple health care services for both
inpatient and outpatients with cardiac diseases.
Provides ongoing evaluations of care management services; works closely with the Cardiology
attending physicians, fellows, Primary Care and other specialties.
Provides clinical support to RNs, LPNs and MSAs in the Cardiology section.
Prescribes interventions and treatments, which may include the prescribing of medication.
Oversees and is accountable for a broad range of health services which include, but are not limited to,
promotion of health, prevention of illness and disability, diagnosis and treatment of acute and chronic
conditions/diseases, and management of health care during the acute and chronic condition phases of
illness.
Consults and collaborates with other health care providers.
Performs quality assurance support as assigned.
Assesses and prescribes intravenous diuretics in an inpatient or outpatient setting.
Assesses and treatments of general cardiology patients, especially those with heart failure.
Works on a flexible schedule that may include nights or weekend coverage.
30
Seasoned professional knowledge; equivalent to a Master's degree; knowledge in more than one
discipline.
Two years as RN; MSN - graduate of Nurse Practitioner Program
2-3 years of recent cardiology experience (IP or OP)
Knowledge and skills with assessment, diagnosis and management of acute/chronic heart failure.
3-5 years of experience. Microsoft Office Suite; Basic computer skills; Cerner; Medical terminology;
Nursing Process skills based on MD Nurse Practice Act; Critical thinking skills; Medical equipment.
WI Registered Nurse License; American Heart Association CPR Certification; CPR Healthcare Provider;
Acute Care Certification; Cardiac Electrophysiology experience encouraged; Current WI Nurse
Practitioner Certification.
Demonstrates the ability to follow verbal instructions, as well as the ability to communicate effectively
both verbally and in writing.
Registered Nurse
Job Summary
Responsible for providing direct nursing care by applying clinical nursing knowledge and skills, and for
ensuring the safety and comfort of patients and families according to legal, organizational and professional
standards. Will also facilitate the Cardiologists treatment plan and collaborate with affiliate providers. Must
also have the ability to triage and evaluate patient with critical cardiac complaints under the direct supervision
of the cardiologist on call or NP.
Responsibilities
Perform physical exams and health histories
Provide health promotion, counseling and education
Administer medications, wound care, and numerous other personalized interventions
Interpret patient information and make critical decisions about needed actions
Coordinate care, in collaboration with a wide array of healthcare professionals
Direct and supervise care delivered by other healthcare personnel like LPNs and nurse aides
Conduct research in support of improved practice and patient outcomes
Active Wisconsin RN license
Minimum of one year clinical nursing experience as an RN in a similar setting (critical care, telemetry)
preferred
Bachelor's degree in Nursing from an accredited college/university preferred; must obtain within 5 years
of hire
Current BLS certification
Current ACLS certification preferred; may be obtained after hire
Registered Clinical Exercise Physiologist

Job Summary
Provides exercise screening, exercise and fitness testing, exercise prescriptions, exercise and physical activity
counseling, exercise supervision, exercise and health education/promotion, and measurement and evaluation
of exercise and physical activity related outcome measures. Works individually and/or as part of an
interdisciplinary team in a clinical, community, and public health setting. Published professional guidelines,
standards, and applicable state and federal laws and regulations guide the practice and supervision of the
RCEP.
Responsibilities
Collects patient assessment data, in a collaborative and ongoing manner.
Collaboratively develops educational goals, learning objectives and a plan for educational content and
teaching methods.
Collaboratively develops an individualized follow-up plan with each patient.
Evaluates effectiveness of educational services provided by measuring attainment of learning
objectives.
31
Documents assessment data, educational plan, educational services provided and evaluation results in
each patients Electronic Medical Record
Utilizes a team approach to provide services and collaborates and communicates with team members.
Identifies when a patients needs are outside the scope of the instructors practice and expertise,
arranges for additional services to meet needs.
Contributes to, and participates in, a continuous quality improvement process
Education
High School Diploma or GED
BS or BS in Exercise Physiology, Exercise Science or related field
Preferred MS or MA in Exercise Physiology, Exercise Science or related field
ACLS and BLS certified/eligible within 6 months of hire
Certified registered exercise physiologist by American College of Sports Medicine or exercise
physiologist certified by the American Society of Exercise Physiologists or pass the tests within 6
months of hire
Qualifications/Skills
Experience
Preferable special internship in hospital cardiac rehabilitation program
1-2 years of cardiac rehabilitation experience preferred
Skills
Completion of EKG interpretation course
Certification in ACLS according to department standards
Flexibility, good interpersonal communication, organizational and documentation skills
Word processing skills
Ability to work independently, initiates and follow through with tasks
Licensure/Certifications
ACLS
BLS
Clinical Exercise Physiologist

Job Summary
Works with heart failure patients in a variety of settings. This job encompasses a variety of responsibilities of
cardiac rehabilitation services. Determines exercise prescription on an individual basis for each patient.
Promotes exercise and activity aimed at assisting patients to return to pre-event level of conditioning.
Responsibilities
Provides fitness and lifestyle assessment. Responsible for development of exercise prescription,
instructions and ongoing re-evaluation of activity until discharge.
May provide classroom education to patients regarding importance of exercise and increased activity,
how to monitor activity, indications and contraindications.
Responsible for monitoring patients during exercise, assessing equipment needs and providing
recommendations to manger.
Performs pertinent chart reviews to determine appropriate activity levels. Communicates plan to other
care providers.
Recognizes the need for and makes appropriate interdisciplinary referrals.
Documents patient's physical activity as well as documenting vitals and clinical response.
Provides patient with self monitoring tools as appropriate.
Perform other duties as assigned
Education
BS or BS in Exercise Physiology, Exercise Science or related field
Preferred MS or MA in Exercise Physiology, Exercise Science or related field
ACLS and BLS certified/eligible within 6 months of hire
Certified exercise physiologist by American College of Sports Medicine or exercise physiologist certified
by the American Society of Exercise Physiologists or pass the tests within 6 months of hire
Qualifications/Skills
32
Experience
Preferable special internship in hospital cardiac rehabilitation program
1-2 years of cardiac rehabilitation experience preferred
Skills
Completion of EKG interpretation course
Certification in ACLS according to department standards
Flexibility, good interpersonal communication, organizational and documentation skills
Word processing skills
Ability to work independently, initiates and follow through with tasks
Licensure/Certifications
ACLS
BLS
Dietitian
Job Summary
Advise and counsel heart failure patients on food and nutrition. They may explain nutrition issues to clients,
assess the dietary and health needs of clients, develop meal plans for clients, gauge the effects of these meal
plans, promote nutrition through public speaking and community outreach programs, and keep abreast of the
latest research in nutritional and food sciences.
Responsibilities
Assesses the nutritional status of heart failure patients through documentation in the medical record.
Uses parameters such as anthropometric measurements, visual assessment and interpretation of
laboratory values
Develops and revises a nutrition care plan based on information from the patient, medical record, family
and health care team members
Incorporates current evidence-based research into practice
Adheres to facility confidentiality, HIPAA regulations, and patient rights policies
Complies with regulatory agency standards, including federal, state and JCAHO as evidenced by
successful completion of surveys with no deficiencies
Completes all required documentation, reports and logs in a timely, professional and thorough manner
Communicates effectively with all team members, patients and families through conferences, individual
consultation and committee participation. This includes telephone, written, and electronic
communication
Orients, mentors and trains staff and interns, as applicable
Advises department on patient care and food service issues
Plans regular and modified menus based on current diet manual
Follows facility and department infection control policies and procedures
Participates in facility-wide and department Performance Improvement Program and on Performance
Improvement teams to improve processes and patient care
Bachelors or advanced degree from an accredited institution with major in Food and Nutrition or Clinical
Dietetics
Successful completion of dietetic internship within a CUP program, internship, or Master's degree
program
Registered, or in the process of being registered within six months of hire date, by the Commission on
Dietetic Registration of the American Dietetic Association
Licensed, or in the process of being licensed within six months of hire date, by the State of Wisconsin
Maintains continuing education hours as outlined by the Commission on Dietetic Registration of the
American Dietetic Association
Appendix D
33
Appendix E
Appendix F
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Business Plan:

Keep It Pumpin Heart Failure Management

Heart Failure Follow-Up

TABLE 9. Break-Even Analysis

End-of-Life Care (NP)

Keep It Pumpin Memberships

Average Cost per Month

Lunch Hour/Additional Office Work

Workforce Flow Chart

Additional Forms of Revenue

Patient Outcome Measurements

The Patient Health Questionnaire (PHQ-9) -http://www.cqaimh.org/pdf/tool_phq9.pdf (actual

TABLE 5. Program Outcome Measurements

< 20% of patients

Employee Satisfaction & Benefits

May accrue a maximum of 120 hours

Heart Failure diagnoses: all diagnosable HF codes with brief descriptions

Risk modification: associated risks/complications of heart failure

Joint Commission program accreditation

Capital & Expendable Expenses

Cost per Item

TABLE 7. Capital Expenses (Plan B)

Cost per Item

TABLE 10: Break-Even Analysis (PLAN B)

Strategy & Implementation

Sponsors & All Members

Sponsors & All Members

Sponsors, All Members, Quality

Sponsors & All Members

Financial Program Assistance

Pro Forma: Plan B (Minimum of 170 patients)

Heart Failure ICD-9 Codes

Keep It Pumpin Job Descriptions

Labs ordered/done prior to first

[If patient answered no, advised the

[If patient answered yes to having a

Have you been weighing yourself

Dry weight (at home,1st day after discharge)

Do you have a weight diary?

If no, was the patient

[Tell patient that he/she should

Registered Clinical Exercise Physiologist

Clinical Exercise Physiologist

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