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Helping Patients Navigate

the Cardiac Care Process
A 58-year-old woman was admitted to the Moses Campus with a non-ST-segment elevation
myocardial infarction and immediately taken to the Catheterization Lab, where a team inserted
two stents into her right artery. With a history of systolic heart failure, she considered herself lucky.
And, when on her sixth day of hospitalization, the nurse told her about the Heart Failure Brown Bag
Clinic, she was happy to listen.

Six months before, in early 2012, Ileana Pia, MD, MPH, Assistant
Chief, Academic Affairs, Cardiology, Montefiore, and Professor,
Medicine and Epidemiology & Population Health, Einstein, began
the Heart Failure Brown Bag Clinic in the Cardiac Clinic space
in the Greene Medical Arts Pavilion. We tell patients to bring all
their medications to us in a brown bag after they are discharged,
she says. The goal of this unique outpatient program is to motivate
patients to adopt healthy behaviors and habits as well as encourage
medication adherenceand thus reduce the likelihood of
readmissions.

The Clinic was born out of a new policy from the Centers for
Medicare and Medicaid Services (CMS), which began reducing
payments to inpatient hospitals with excessive readmissions for
patients who suffer from heart attacks, heart failure and pneumonia.
Patients who are treated for a condition at the hospital but then
neglect to properly care for themselves after discharge often wind up
back in the hospital, significantly adding to healthcare costs.
Based upon the success of Montefiores Heart Failure Brown Bag
Clinic, Montefiore was one of 15 institutions nationwide selected

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to participate in the American College of Cardiologys (ACC)

Patient Navigator Program. The goal of the Patient Navigator
Program, much like the Brown Bag Clinic, is to reduce heart
failure readmissions.
The Patient Navigator Program places patients and providers
at the center of a comprehensive community of care. Through
this program, patients and their referring physicians gain access
to: a team of specialists, all of whom have extensive experience
managing every facet of heart failure treatment; an individualized
treatment plan featuring medication, dietary and lifestyle
recommendations and counseling; intensive care management,
including weekly reviews of treatment plans, frequent follow-up
calls and visits and close communication with the primary care
physician; resources such as support groups and access to worldclass surgical therapies; and access to clinical trials, which explore
the most up-to-date medical devices, treatments and therapies.
Cardiac patients who are treated at Montefiores Moses Campus
are met at their bedside by a nurse manager, who schedules their
follow-up appointment as part of this innovative program.

Increasing Patient Education

Upon arrival at the Heart Failure Brown Bag Clinic, patients
complete a KCCQ (Kansas City Cardiomyopathy Questionnaire),
a self-administered questionnaire that quantifies a patients
physical limitations, symptoms, social function, self-efficacy and
general quality of life.
The patients then have their vitals taken by a nurse and meet with
two pharmacists and a heart failure nurse practitioner. After a
thorough review of all of their medications, those that are deemed
to be unsuitable or unnecessary are handed over and properly
disposed of, says Lendita Prlesi, PharmD, Clinical Pharmacy
Manager, Montefiore Care Management Organization (CMO).
As part of the arrangement with referring physicians, pharmacists
in the program are able to review medications, says Dr. Prlesi.
New medications are ordered electronically or the patient is given
a prescription.
The next step is education. This can last for as little as 30 minutes
or up to an hour and a half, depending on the complexity of the
patients needs. Non-native English speakers have the Montefiore
Translator Line available for use, says Dr. Prlesi. It is important
for patients to understand why they are taking each medication,
what it does in their body, and how it should be takenfor
example, should it be taken at night, or taken with food? We also
point out that when taking certain medications there are foods that
should be limited or avoided.
Dietary concerns are the next focus for the patients. We
explain that eating too much salt, which is found in
almost all processed and packaged foods, will
cause them to retain water. We recommend
that they limit salt intake to two grams per
day or avoid it and try a salt substitute
instead, says Dr. Prlesi. Patients are

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Medicine@Montefiore

also counseled to limit their fluid intake to a maximum of 64

ounces of liquid a day. The key is to make the patient aware of all
the components of those 64 ounces. It is not just water; it is also the
liquids in soups, coffee, tea, soda or juice. Its a matter of getting
them to see a different picture, have another perspective of what
they are consuming, Dr. Prlesi says.
Another lesson imparted to patients is the importance of weighing
themselves daily, staying active and getting at least 30 minutes of
exercise per day. Patients are taught to correlate a weight gain
of three or more pounds within three days or less with water
retention, says Dr. Prlesi. They should call their doctor for
instructions on what to do.
We refer patients to a cardiologist if they dont already have one,
and we address whether or not our patients have any transportation
issues that could prevent them from going to their scheduled
doctors appointments, she says.
When a patient requires transportation, Montefiore social workers
help to arrange for Access-a-Ride or other means. Patients also
receive a routine baseline PHQ9 depression screening assessment to
decipher if there are any further needs that may have been missed,
says Dr. Prlesi.
Before they leave, Patients receive a heart failure educational
booklet that contains everything that was discussed at the visit
with all relevant contact information, she says. They also get a
medication pocket recorder with all their updated medications
and instructions.

Ensuring a Smooth Transition from Hospital to Home

When the Heart Failure Brown Bag Clinic program was started
several years ago, it was very innovative and successful, says Donald
Stark, MPA, Director, Clinical and Business Affairs, Division of
Cardiology, Montefiore. So when the ACC announced a program
that applies a team-centered approach to keeping patients at home
and healthy after discharge, Montefiore applied and was accepted.
One of the reasons that Montefiore was chosen to be a part of the
ACC Patient Navigator Program is we already have a successful
outpatient program in place, and we were using our resources
to ensure that cardiac patients were not readmitted for the same
problem, he says.
The Patient Navigator Program will provide personalized support
to heart failure patients as they transition from hospital to home.
This is vital because cardiovascular disease impacts every patient
individually. We believe strongly in the team approach to

The ACC grant will aid us

in improving and prolonging
patient lives by teaching patients
to take control of their health.
Donald Stark, MPA
Director, Clinical and Business Affairs
Division of Cardiology, Montefiore
medicine, especially for patients suffering from serious heart
conditions, Dr. Pia says.

Navigating Patients Through the System

Montefiores multidisciplinary Patient Navigator team will
consist of a cardiologist, a heart failure nurse practitioner, a
pharmacist and a physical therapist. The team serves as the
patients advocate during the transition in care, with the aim of
discharging patients on a timely basis, identifying those who are
at an increased risk for readmission, and providing resources to
help prevent avoidable readmissions.
In addition to the core team, patients will also have access to the
services of nutritionists, mental health experts and social workers.
To ensure the Patient Navigator Programs success, Dr. Pia says
she and her colleagues are working to identify which patients
will benefit from this program. The ACC created the Patient
Navigator Program to support a team of caregivers at selected
hospitals to help patients overcome challenges during their
hospital stay and in the week following discharge, a period
during which they are most vulnerable.
Not every patient has the same needs, Dr. Pia says. We will
handle the educational aspect while the patient is in the hospital,
and well also arrange for the transition upon discharge. Well
address such questions as: Are they going home, or are they
going to an extended care facility? Is there anyone at home to
help them? Thats the goal of the programto navigate the
patient through the system as smoothly as possible.
Mr. Stark says, We are also empowering patients and teaching
them to take care of themselves. They are learning to exercise
and eat right.

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