Heart failure affects around 6.2 million adults in the United States and is one of the leading causes of hospitalizations nationwide.

VA cares for Veterans with heart failure through efforts such as specialized heart failure clinics, pharmacists, and the Remote Patient Monitoring – Home Telehealth (RPM–HT) program.

Veterans enrolled in RPM–HT receive remote monitoring technologies to track their weight, blood pressure and heart rate daily. Care coordinators (typically registered nurses) call the Veterans when these vitals go outside of specified parameters.

Quality improvement initiative brings disciplines together

This year, a group at Los Angeles VA integrated RPM–HT with support from cardiology and pharmacy staff to create an initiative that is optimizing care for Veterans with heart failure.

Dr. Kim Lynch

That group consisted of Dr. Kim Lynch, a general internist and VA advanced fellow in the National Clinician Scholars Program; her mentor, Dr. Shelly de Peralta; a nurse practitioner in cardiology; Dr. Donald Chang, a consultant cardiologist, and several RPM–HT nurses.

In 2020, Lynch identified an increase in the number of heart failure patients who had been admitted to the hospital two or more times in the past year. Further inquiry revealed issues related to care coordination.

These included the lack of a consistent provider, follow-up care, and the ability to track blood pressure and weight at home. It also revealed that issues with medications were the leading cause of readmissions.

Lynch and de Peralta conceived a quality improvement initiative to bring together the various disciplines — cardiology, pharmacy, and RPM–HT — to reduce hospitalizations and optimize care for those at-risk Veterans.

Idea came from helping her Veteran grandfather

For Lynch, this initiative hit home. When she was in medical school, her grandfather, an Army Veteran, confessed that he would occasionally miss a day of taking his diuretic medication. As a result, his ankles were swelling.

Dr. Shelly de Peralta

Lynch suggested taking an extra dose the day after any missed dose to relieve his symptoms and wondered why his VA care team hadn’t suggested that. She believed care teams should have the medications, the technology and the evidence to improve medication management for Veterans.

Lynch’s team got to work. In November and December 2020, they conducted a literature review of national care coordination programs for Veterans with complex conditions such as heart failure. The evidence indicated that these programs could reduce admissions for such conditions if the right providers delivered the right care at the right time.

Nurses developed template for signs and symptoms

In January 2021 the team began the pilot intervention. They identified the target group as all Veterans who had been admitted to the hospital twice or more in the last year. Three RPM–HT nurses would also take part.

The intervention had two objectives. The first was to engage RPM–HT nurses and VA pharmacists to improve home tracking of symptoms, vitals, and medication management. The second was to give each Veteran a consistent VA provider in the chronic heart failure clinic.

The provider would interact with the Veteran, RPM–HT nurses and pharmacists would provide timely, problem-directed interventions. VA staff members would communicate through secure messages to manage Veteran care.

The nurses who participated in the pilot collaborated with Lynch and de Peralta to establish a questionnaire, or “template,” about the signs and symptoms of heart failure since the Veteran’s last evaluation. The template is based on questions from the American Heart Association. It addresses diet, leg swelling, medication adherence, shortness of breath and more.

The pharmacists also designed a template to collect data on pharmacy-sensitive measures. The focus of this data collection and care was on heart failure-related, guideline-directed medical therapy initiation and optimization.

Weekly meetings to review best options

The process starts when the RPM–HT care coordinator calls a Veteran weekly and uses the template to assess for changes in symptoms. The care coordinator also initiates a call any time a Veteran’s device-recorded vital signs or symptoms are outside of provider-specified parameters.

The coordinator then communicates the clinical assessment with the Veteran’s cardiology provider through a secure message. The cardiologist reviews the information and decides on an appropriate intervention for the Veteran, which may include a medication adjustment. The pharmacist assists in processing any medications using the data obtained from the RPM–HT Care Coordinator’s calls.

The cardiologist and pharmacist meet weekly to discuss the Veteran’s clinical status. They also gather data and review the best options for adjusting medications based on medical therapy. The team’s timely interventions and ongoing medical therapy are crucial to stabilize the Veteran’s heart failure and prevent hospitalizations.

Pete and Blanca Perales

75% decrease in emergency room visits and hospitalizations

By mid-February, the initiative expanded to include six RPM–HT care coordinators and registered nurses. From April to July, the team collected data and tracked the progress of more than 30 Veterans.

The results of the program have been impressive. Among the 30 Veterans who are actively sharing vital signs weekly, there was a 75% decrease in emergency room visits and hospitalizations post-intervention, compared to pre-intervention. In addition to health benefits for Veterans, these results inform potential cost savings for both Veterans and VA.

“Being part of the program has been great,” said Pete Perales, a Veteran enrolled in the initiative. “I rely on my nurse to give me advice and remind me to take my medications. Because of her, I have not been admitted since last year.”

His wife, Blanca Perales, agreed. “This program keeps him on track. Pete looks forward to her calls. We are very happy with the program.”

A cardiology nurse practitioner noted the benefits to providers as well. “This is helping me a lot. I am now spacing out my patient appointments from once a week to once every two weeks. And I’m more comfortable doing phone appointments because I have the vitals and the template. And I can trust that the information is reliable.”

Multiple disciplines collaborating benefits Veterans

Lynch hopes other VA care teams can use this program as a model for bringing evidence-based practices to Veterans who are high-risk heart failure patients.

“This program really highlights the collaborative nature of multiple disciplines that can come together for the benefit of the Veterans,” de Peralta said. “People have said this could be a game changer in the management of high-risk heart failure patients.”

For more information on meeting with VA providers virtually and sending health data from home, check out the VA Telehealth Services website.

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