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Brian Kruger never felt the jolt of the defibrillator that gave his heart a jump-start last month. He fainted, and smashed face first into the concrete floor while on the job at a Sears Auto Center.
By the time paramedics wheeled him into Fairview Southdale Hospital in Edina, a team of heart specialists who knew him well had already swung into action. Emergency room doctors had Kruger's history of heart problems at their fingertips. A favorite nurse was soon at his bedside.
"The phone calls had already been made before I got there," said Kruger, 49, who is part of an intensive heart program through Fairview known as the C.O.R.E. Clinic. "It helped to see a familiar face."
With a team of nurses and cardiologists scrutinizing the condition of patients and coaching them on lifestyle choices, the Fairview program has had measurable success keeping Kruger and other heart-failure patients from boomeranging back into the hospital.
Since 2003, when the C.O.R.E. Clinic launched, heart-failure patients have had a 67 percent lower rehospitalization rate compared with those not in the program, according to Fairview. Last year, about 14 percent of patients with heart failure were readmitted within 30 days, compared with the national average of 25 percent.
Keeping Kruger and others like him out of the hospital for good may be an unrealistic goal. The Apple Valley man was diagnosed with an enlarged heart when he was 38 and has multiple other health issues, including diabetes.
But C.O.R.E.'s five-step approach of evaluation and intensive follow-up to stay on top of symptoms has been effective enough that Fairview is in the process of rolling it out to other heart clinics, starting with the University of Minnesota Medical Center and Fairview Ridges. Officials hope it could be used as a national model.
"The breakthrough had to do with the fact that these patients were being seen frequently, that educational issues were being introduced and reintroduced, and the time was actually spent with the patient talking about things specifically regarding their lifestyle," said Dr. Eric Ernst, a cardiologist and medical director of the C.O.R.E. Clinic. "In the past, heart failure was managed by individual doctors who saw their patients occasionally, when they had time -- typically when their patients were having problems."
Pressure to cut costs
The nation's hospitals are focused on getting a handle on hospital readmissions, because they are a costly drain on the health care system. As part of the Affordable Care Act, which is being considered by the U.S. Supreme Court, hospitals with high readmission rates will pay a financial penalty starting in 2013.
Patients with chronic heart failure account for the largest percentage of rehospitalizations, making it a key area for reform.
In Minnesota, one in eight hospitalizations are related to cardiovascular disease at an annual cost of $1.8 billion, according to the most recent data from the Department of Health.
While there's a lot of talk these days about coordinating and managing care, it's difficult to pull off and even more challenging to duplicate programs across a large hospital system with a network of primary care locations and specialty clinics.
"Of all the initiatives I've heard about, the ones that appear the most successful are those that link all the activities to electronic health records in creative ways," said Stanton Shanedling, supervisor of the state's Heart Disease and Stroke Prevention Unit. "It takes primary care doctors and cardiologists. It takes pharmacists, social workers, nutritionists, exercise physiologists. It's a team effort, coordinated electronically."
Fairview's program is one of several to take on readmissions for heart patients.
Park Nicollet has been part of a five-year federal demonstration project, and showed similar success with 500 congestive heart failure patients using phone questions and nurse follow-up. Officials at the St. Louis Park-based hospital estimated that the call-in program alone avoided one hospital visit per patient per year, and if adopted nationwide would save taxpayers $25 billion.
Clinicians at Regions Hospital in St. Paul have spent the past year focusing on uninsured and very poor patients with heart disease, with early signs of success. One program enlisted patients in twice-weekly intensive rehabilitation sessions for eight weeks, going so far as to pay cab fare to get patients to show up. To date, only one of 20 patients in the program has been readmitted.
A "medication boot camp" has patients take part in a role playing situation while they're still in the hospital to see how well they'll be able to manage their prescriptions when they get home. A third program sends nurses, social workers and physical therapists to patients' homes.
Regions officials said the readmission rate for heart failure patients within the first 30 days was 19.2 percent in 2011, down from 22 percent the year before.
"The common thread is that we can't wait for patients to identify their own symptoms and take care of themselves at home," said Mike Cannon, Regions' director of nursing, cardiovascular services. "If we want to keep them out of the hospital, we have to reach out to them after they've left here."
With Fairview's C.O.R.E. Clinic program, nurses or nurse practitioners meet with patients before they leave the hospital and start coaching them on medication. They make house calls if need be. Some patients call in every day and answer simple questions about their health, and most step on a scale to monitor rapid weight gain, a sign of dangerous fluid retention.
Patients have the phone number of someone they can call directly with questions. Clinic nurses check in with the the patient's primary care doctor. If blood work gets ordered up, the C.O.R.E. teams make sure results get shipped to all of the patient's caregivers.
"It's not all about readmissions," said Kris Mannchen, the nurse practitioner who designed the program for the C.O.R.E. Clinic. "It's about quality of life."
Mannchen said the payoff comes because the team becomes hyper-focused on what's going on with the patient both inside and out of the clinic.
"We may figure out they need help setting up medication," she said. "Maybe they live alone and can't cook very well, and we can get a social worker out to help. We find all these issues going on in their life and that's why they've been readmitted."
John Mares, 50, has been coming to the C.O.R.E. Clinic since April 6, 2005, when he had two heart attacks.
"I had no clue about anything," he said. "I had all these questions. Am I going to be able to work? How will I live?"
Mannchen helped him start a low-sodium diet and referred him to a sudden cardiac arrest survivor network, where he could talk to other people.
"I ride a bike, I golf. I can do so much more now than I ever thought," said Mares, who is back to work as an insurance salesman. "The message is hope."
Jackie Crosby • 612-673-7335