Gina Kaye (Host): Welcome to A Look at Managing Heart Failure Differently: Inside the CHF Infusion Clinic is our topic on this episode of Curating Care, a podcast brought to you by St. Clair Health, expert care from people who care. I'm your host, Gina Kaye, and joining me are Courtney Hippert, a certified physician assistant, and Dr. Christopher Pray, cardiologist here at St. Clair Health. Courtney and Dr. Pray, it's great to have you.

Courtney Ann Hippert, PA-C: Thank you for having us.

Host: Today, we are talking about managing heart failure differently. I'm sure our audience is excited about this topic, so let's dive into our questions. To start, can you walk us through what the CHF Infusion Clinic is and the problem it was designed to solve?

Courtney Ann Hippert, PA-C: Absolutely. I'll start with this one. You know, the CHF Infusion Clinic is really designed to be a collaboration between our heart failure clinic here at St. Clair, as well as our infusion center. And it's really meant to manage patients with acute decompensated heart failure who are experiencing worsening symptoms in an effort to provide IV diuretics as an outpatient, and hopefully reduce their risk of admission to the hospital, and really improve patient quality of life and keeping them home to provide their care in their home environment.

Christopher Pray, MD, FACC: I agree, Courtney. And I think I would just add, you know, the infusion clinic and this pathway, I think, is one piece of a larger puzzle that we've all collaborated together to design. And St. Clair Health has really invested the resources into trying to provide care for patients with heart failure at our institution in a way that is very patient-centered and a little bit different than how things have been done historically.

I think trying to care for patients with an organized team structure. So, Courtney is an APP, a physician assistant, and she's managing patients alongside the cardiologists, our pharmacists, our nurses, our entire staff, both in the hospital as well as out of the hospital. And the infusion clinic is one way, one tool really, that we have to offer patients that may help alleviate symptoms. It might help prevent the need to actually be admitted to the hospital. And so, it's another resource, but one of many that I think are emblematic of the investments in the infrastructure that St. Clair has put forward into trying to improve this disease state, congestive heart failure, because this is a large need of our community

Host: That's fantastic. It sounds like you guys really have your work cut out for you.

Christopher Pray, MD, FACC: We're all very passionate about it.

Host: I could tell.

Christopher Pray, MD, FACC: I think for Courtney and I both, I think, it comes naturally and I think, it's one of the most rewarding endeavors that we've been a part of.

Courtney Ann Hippert, PA-C: Absolutely.

Host: That's great. How do you determine then which patients are appropriate candidates for outpatient IV diuretic therapy maybe versus just hospitalization?

Courtney Ann Hippert, PA-C: Obviously, something we manage and navigate every day in the clinic. So, our clinic is really supported by, several advanced practice providers, both PAs and nurse practitioners. And usually, we're starting that initial kind of evaluation of the patient and navigating their management and their fluid levels and kind of how they're feeling from a heart failure perspective.

It's really the patients who, despite using diuretic, oral diuretic medications, they're really not responding and their symptoms aren't improving. And so then we ask ourselves the question, "How can we better assist and improve their symptom state?" And we start to talk about adjusting oral doses of diuretics and increasing medications, but really we've come to learn that our IV diuretic and the infusion center agreement really helps us offload these patients and improve their symptoms much more quickly and efficiently. And it makes patients feel better overall. And really, between our outpatient visits within our clinic and the collaboration with the infusion center particularly, we've really improved leaps and bounds on how efficiently we can improve heart failure management.

Christopher Pray, MD, FACC: Courtney, I think that you summarized that complex problem and complex question into a very simple answer. And I think that's also very representative of, you know, how you approach these patients with congestive heart failure. I mean, Courtney and her team of APPs in the heart failure clinic, they all have, you know, expert specialized training in managing patients with heart failure.

Andour heart failure patient population is of our most complex, complicated, and highest needs population that we help to manage and take care of. And I think that the nuances in trying to decide which patients are best served in a hospital with oral diuretics or in an outpatient setting with IV diuretics, I think as Courtney said, every day she makes complex problems look easy. And I think it really is a hard question to answer. There's a lot of style and a lot of subtleties that go into making that appropriate decision.

All I can say is having a team that does this day in and day out rather than, you know, in a historic sense, a lot of hospital centers have everyone participate in the management of complex heart failure patients. And it might be a small percentage of what they do every day. And I think the lessons that we learn in life and in medicine in particular are that if we subspecialize ourselves and we do fewer things more often, we probably in most cases in life do them better.

All I can add is that I think the trust that the physicians have with our APP colleagues in the heart failure clinic and our nurse navigators and our nurses is really, really great. It's earned respect. And I think that the way that we approach that problem and how to triage where a patient goes, there's really a lot that goes into that every day, even if it looks simple.

Host: Making it look simple to the patients is always the goal, I think, correct?

Courtney Ann Hippert, PA-C: Absolutely.

Host: Right. What does a typical visit look like for a patient from arrival through discharge of your clinic?

They typically start in the heart failure clinic. They're evaluated by one of our advanced practitioners. You know, we're checking routine vital signs, blood pressures, making sure the patient's doing well overall. And we're really looking at other comorbidities as well. So, chronic kidney disease as one example, and making sure kidney function is stable, blood pressure is stable, and really deciding overall the trajectory and decision to refer to the infusion center to start.

And once we decide to make that referral, typically we just call over to our colleagues in the infusion center, and we arrange a follow-up visit for the patient with them. That usually occurs within the same day of their clinic visit, to be honest. And if it's not the same day, it's usually within 24 hours. So, we try to get them in pretty quickly. And then, we have a pretty rigid kind of protocol for them to follow up there. It's usually about three sessions of IV diuretics three days in a row.

And we monitor in real time how the patients respond. And then following that third day of IV diuretics, we usually like to see them back in the heart failure clinic, typically within seventy-two hours of that last IV diuretic dose. That gives us the opportunity to make sure they've responded well, but also gives us the opportunity to make sure with their symptom improvement, how can we as providers keep them there and continue their management with oral diuretics overall and just make sure they're continuing to feel well.

Christopher Pray, MD, FACC: What Courtney just summarized, I think, is unique. Very few hospital centers offer what essentially translates to inpatient level of diuretic care. It's the same therapy that we would be providing that patient whether they're in the hospital, but in an outpatient setting in this instance.

And that enables us, I think, to avoid some of the—there's always risks to hospitalization, but one of the big risks is just being cooped up in a hospital bed. And our patients will become a little bit deconditioned. And that muscle weakness that comes from a hospital stay, we understand has ramifications. And so, our goal is always to let patients return to the same place that they came from. If they came from home, we want them to go home rather than a rehab center, if at all possible, because we know that patients prefer that, and they do better if they're able to. So, this protects their functional capacity a little bit more.

And again, I just think from the patient experience viewpoint, I think it's unique to be able to receive care in a center that is able to kind of reach out and meet the patient where they are and try to keep them there rather than bring them back into the hospital. So, I hope tha in our design of this program, I hope that the patient and experience is satisfactory. All of us, I think we put a lot of effort into trying to design it that way.

Host: That's great. It seems like that would also help empower the patient a bit as well if they weren't stuck in a hospital room per se.

Christopher Pray, MD, FACC: You're absolutely right. I mean, I think, it's hard, you know, when you're in a hospital, you're automatically going to be hooked up to IVs and monitors. And sometimes, you know, the hospital bed has alarms on it and your sleep is disrupted. And, you know, it's not that we for those disruptions. But they're kind of a necessary part of providing really intensive, aggressive care in the hospital so that we can ensure patient safety.

Whenever safe and possible for us to be able to provide care in a different manner that lets those patients stay home, I think it's a compassionate and dignified way of offering care. A lot goes into the decision-making. We're very careful in terms of how we select those patients that can receive care in this pathway versus the hospital. But in the right patients, I think it adds a lot of meaning for them.

Host: We talk about symptom improvement a little bit. We'll switch gears a little bit. What are the clinical goals during an infusion visit, and how quickly do patients typically see their symptoms improve?

Courtney Ann Hippert, PA-C: Obviously, the goal of the clinic and the goal of the infusion center is to certainly see a symptom improvement. Ideally, in a perfect world, we want symptom resolution. We want these people to feel dramatically better than where they started, and that's always the goal.

And I think, you know, it also gives us this added opportunity to kind of build these relationships with our patients with chronic disease management and continue to get close to them and their families, get to know them, and build this level of trust with them. And it gives us the opportunity, an added touch point of education, whether that's education of early recognition of heart failure signs and symptoms, or whether that's some dietary education and dietary daily restrictions. We try to empower our patients with as much education as possible to obviously prevent this as well. So, the infusion center also, you know, one of the goals of it is just added education for the patients to hopefully avoid continuous visits in the future if they can.

Christopher Pray, MD, FACC: I think going along, you know, building these longitudinal relationships. And one of the most important lessons I think that we have learned in heart failure management is that traditional practice, cardiology practice in the US currently, these patients may be seen once a year, maybe twice a year, maybe three times a year. But it's pretty hard to get an urgent appointment or it's pretty hard to get an appointment after a hospital discharge.

So, what we've taken from that and the actions that we've made have been to try to, with Courtney and her team, including a dedicated nurse navigator who really makes the patient experience, I think, a lot more streamlined. We've really tried to increase the number of those touch points that Courtney alluded to by offering not only urgent, as-needed office appointments if a patient is struggling with worsening symptoms. You know, we're able to get patients in much more quickly than we've been historically able to in our practice with the cardiologist only. And we're able to see patients who maybe need more intensive adjustment of those medications or maybe need more frequent IV dosing, we're able to see them much more often.

To Courtney's point about building that relationships, we're really seeing the benefit of that, not just in patient outcomes, but I think the meaningful relationships that develop along the way in these patients and their family members. You know, we're frequently touched by that. The feedback that we've received, this has been quite openly from the community.

Host: Patient safety is a huge topic of conversation in the healthcare world. So, tell the world then how do you ensure patient safety during an outpatient IV diuretic treatment?

Courtney Ann Hippert, PA-C: So, we have a very strict protocol that we use in collaboration with our infusion center. And we have the opportunity, , with these touchpoints, to check vital signs, routinely obviously, and then keep a close eye on monitoring kidney function and, you know, other labs like that.

It gives us the opportunity really to adjust our management of heart failure symptoms, while also keeping an eye out for other comorbid conditions that often accompany heart failure, as well as, you know, just overall making sure we know that heart failure management can come with side effects, and the medications that we use can come with side effects.

And our protocol really pays close attention to all of the possibilities of both comorbidity management and side effect profile that can come with the medications that we're using. It's really nice flow that we have.

Host: How does the CHF Infusion Clinic improve coordination, because we all know it takes a village, between cardiology, primary care, and other members of the care team?

Courtney Ann Hippert, PA-C: You use my favorite line, it really takes a village. Dr. Pray here has pointed out a couple of times how many people are actually involved in this clinic, and we have many wonderful staff that really support our clinic. A group of advanced practice providers, both PAs and nurse practitioners.

We have wonderful cardiologists here at St. Clair that support us greatly as well. We have nurse navigators. You know, we have really, really great staff, pharmacy, all of these people kind of supporting the same mission. And ultimately, our goal is to really take high-quality care of our heart failure patients. And it absolutely takes a village. There's no doubt about it.

Christopher Pray, MD, FACC: Perfectly said. Very much so, yeah.

Host: So, let's talk about the future for a moment. So looking ahead, how do you see outpatient heart failure management evolving over the next few years?

Christopher Pray, MD, FACC: We're trying to be on the forefront of that. I think when we look at the prevalence of heart failure, so for those alive today, over the course of our lifetime, about one in four people will develop heart failure. So, this is going to be a disease that has a very high prevalence. We know that these patients require a lot of care, and we know that care can be costly in medicine.

So, we're trying to not only improve the quality of care by helping patients receive care as part of a collaborative team in a safe pathway, but be able to provide different outlets and avenues for them to receive that care rather than just in a traditional cardiology practice, having a standalone group of expertly trained, you know, specialists who are focusing on heart failure that's a multidisciplinary team, I think, has very strong benefits to offer. I think that being able to provide outpatient IV diuretic therapy, while it may be unique to some institutions currently, I think that it's a much more cost-effective approach than hospitalizations and rehospitalizations, as well that these patients with heart failure really do end up with multiple hospitalizations throughout their life. And each time they're hospitalized, their overall prognosis seems to worsen.

So, we're trying to do things a little bit differently. We're trying to involve multiple different members of the healthcare village that we all work with and stay on the leading edge. I think everyone involved in this team is really well-trained. They're very highly skilled healthcare professionals. They're really passionate about providing excellent care, especially when it comes to heart failure patients. Making sure that we understand why that patient has heart failure. Not just that they have it, but trying to understand any underlying conditions that we can target and try to improve, and to do so in a cost-effective and patient-centered approach.

And so, as we learn more as a field, we at St. Clair Health, we try to implement the knowledge that we've all gained. And I think that also unique to us at St. Clair, most of us are caring for our neighbors. Most of us are living in the communities that we practice in. And so, we all take a very personal approach to, I think, each patient that we're caring for. Several times these are family members or direct neighbors. And so, I think, the unique mindset that we all gain from practicing in that type of environment serves as a motivation for us to deliver not just the most current and accurate medical care, but to do so in a very meaningful, cost-effective, and compassionate way.

Host: Before we wrap up the conversation today, is there any last words of wisdom that you'd like to give the listening audience?

Christopher Pray, MD, FACC: Just to give everyone a sense of how much effort has gone into building not just the heart failure diuretic pathway or the heart failure clinic, but the entire team of individuals, the people, I think, are what make St. Clair truly special and truly stand out from other healthcare institutions in our area.

And I think I just want to express my gratitude and the pride, the sincere pride that I have for being able to show up and work with everyone. They're the most talented and, you know, highly trained, very skilled, rofessionals that it's just a pleasure to be associated with everyone.

So, I think I speak for the whole team when I express our gratitude for the efforts that everyone puts into caring for our patients. And like I said, it's the honor of my career to be able to say that.

Host: Courtney and Dr. Pray, thank you so much for your time today. I'm sure your information has truly made a difference.

Christopher Pray, MD, FACC: Thank you very much for having us.

Courtney Ann Hippert, PA-C: Thank you.

Host: Absolutely. For more information about today's episode, please visit stclair.org and search CHF Infusion Clinic. If you enjoyed this podcast, please share it on your own social media channels. This has been Curating Care, a podcast by St. Clair Health. Thanks for listening.