Personalized Care at the C.O.R.E. Clinic for Heart Failure Management

By Melissa Moore
Tuesday, January 31, 2017

The University of Minnesota Health C.O.R.E. Clinic provides a structured approach designed to help patients with heart failure avoid hospitalization, live longer and enjoy a higher quality of life.

More than 100,000 Minnesotans are currently living with congestive heart failure, at an annual expenditure exceeding $25,000 per patient, according to the Minnesota Department of Health. The cost increases to nearly $27,000 annually for congestive heart failure patients with coexisting conditions — more than 55 percent of congestive heart failure patients enrolled in Medicare fall in to this category.

The C.O.R.E. (Cardiomyopathy Optimization, Rehabilitation and Education) Clinic for Heart Failure Management brings together a team of allied specialists to enhance management of the condition. Its mission is to assist individuals with heart failure by addressing the physical, emotional and financial realities of living with the chronic condition.

“Management of congestive heart failure has become increasingly complex, becoming a subspecialty within cardiology in its own right,” says Eric Ernst, MD, FACC, cardiologist with University of Minnesota Health Heart Care and Medical Director of the C.O.R.E. Clinic. “Those who manage heart failure have to understand how to engage a wide variety of resources and tactics in the care of each patient’s individual, complex cardiology needs.”

What’s in a name? C.O.R.E. stands for Cardiomyopathy Optimization, Rehabilitation and Education.

Pursuing Excellence

By incorporating a multidisciplinary approach, the C.O.R.E. Clinic has been able to address the many needs of patients with congestive heart failure. The C.O.R.E. Clinic was developed to provide a systematic approach to personalized care. Five distinct phases — evaluation, optimization, resynchronization, stabilization and restabilization — are used to ensure patients receive in-depth assessment, treatment, education and support. Heart failure experts at University of Minnesota Health Heart Care established the innovative program in 2003. Since then, it has expanded to additional locations, including Fairview Ridges Hospital, Fairview Southdale Hospital, University of Minnesota Medical Center, Fairview Clinics – Fridley, and Fairview Northland Medical Center.

Growth has not diminished the group’s passion for excellence. For the past three years, three hospitals where the C.O.R.E. Clinic is available have earned the Gold Plus Award in heart failure care from the American Heart Association’s Get With The Guidelines Awards. They are also consistently recognized as high performing in heart failure care by U.S. News & World Report. Thanks to C.O.R.E. Clinic initiatives, readmission rates for heart failure patients have dropped to 17 percent throughout program locations, a number well below the national readmission rate average of 24 percent.

“What we do very well is keep our patients out of the hospital,” says Dr. Ernst. “The patients who are hospitalized tend to be the sickest of the sick. We work to reduce hospitalizations and mortality rates, allowing our patients to maintain a high quality of life for as long as possible.”

Advanced, Hands-on Care

Patients referred to the C.O.R.E. Clinic are evaluated by cardiologists to determine their treatment needs. Depending on the severity of a patient’s disease process, a variety of treatment protocols may be utilized, including medical therapies that can decrease or reverse the progression of the disease. Tools used to diagnose and treat heart failure include:

  • Cardiac-assist devices
  • Cardiac surgery
  • Extracorporeal membrane oxygenation (ECMO)
  • Heart transplant
  • Medical management
  • Outpatient infusion clinic
  • Oxygen therapy
  • Ventricular assist device

In addition to procedures necessary to treat cardiac issues, medication optimization and patient education are key parts of the condition’s management. This may include frequent office visits with nurse practitioners and physician assistants.

During these office visits, patients not only address medical needs — such as adjusting medication levels — they also receive assistance with making lifestyle changes and overcoming socioeconomic barriers to care. For patients with heart failure, affording medication can present a challenge. So can following a strict schedule of medication therapy. Nutritional education about a low-salt diet is a vital part of care, as is understanding how to circumvent barriers to exercise, such as joint pain or access to safe fitness facilities. Cardiac rehabilitation is also available to heart failure patients participating in C.O.R.E. Clinic programs who could benefit from regular, structured exercise. These programs are particularly helpful to patients with cognitive impairments who struggle with remembering instructions, fitness schedules or why medication is necessary.

Throughout these visits, nurses and advance practice providers are vital to providing the necessary tools for lifestyle changes.

“I cannot oversell the importance of advanced practice providers who see patients day-in and day-out,” Dr. Ernst says. “As heart failure physicians, we consider regular in-clinic monitoring an integral part of care. Having routine visits with the same individuals and creating relationships with them help keep patients from feeling overwhelmed by the volume of information they need to know about managing their conditions. Our nurses know patients like family members — they know their habits, tendencies, diets and levels of understanding. This provides a safety net for patients. They have someone who understands them, has a relationship with them and knows what to do if they start having problems. We encourage our patients to use us as a resource rather than the emergency room if at all possible. ”

From left to right: Eric R. Ernst, MD, FACC, Medical Director of the University of Minnesota Health C.O.R.E. Clinic; Kristine Mannchen, MSN, CNP, Program Director; and Sara More, PA-C, MS, BS

Embracing Technology

As the C.O.R.E. Clinic team and patients’ primary care providers work to optimize care, remote monitoring can be a huge asset. Access to a readily available support network of providers plays a large role in determining whether or not patients’ treatment plans are effective. The C.O.R.E. Clinic relies on telemanagement to provide close, individual monitoring for individuals who are at home.

A touchtone telephone service is the cornerstone of the C.O.R.E. Clinic telemanagement program. This system allows patients to record their weight as well as answer other basic symptom-related questions.

“If their weight is outside designated parameters or if their symptoms are becoming worse for any reason, our nurses engage with patients over the phone to discuss what is happening and ascertain why the situation may be worsening,” Dr. Ernst says. “Oftentimes, we can make that assessment and a necessary adjustment without making patients come into the office. We may need to change their medications over the phone. The telemanagement program also helps alert us if the patient needs to come to the clinic for an urgent visit. The ideal patient for remote monitoring is one who is motivated to be compliant with medications, but may struggle with managing their conditions. These are the types of patients who end up hospitalized frequently, despite the fact that conservative care measures may be more appropriate. This program can provide more insight as to why continued readmissions are taking place, and, hopefully, help reverse the trend.”

For those in need of more advanced remote monitoring, the C.O.R.E. Clinic offers options such as the CardioMEMS HF System. This system uses an implanted sensor to measure and monitor pulmonary artery pressure and heart rate. Measurements are sent to the clinic on a daily basis, allowing the care team to better evaluate hemodynamics and offer treatment before patients become symptomatic.

Managing Arrhythmias

In addition to addressing heart failure directly, heart rhythm problems are part of standard evaluation and treatment at the C.O.R.E. Clinic.

“Electrical problems can often worsen congestive heart failure by compromising pumping function and causing uncontrolled heart rate,” says Dr. Ernst. “Knowing how and when to engage electrophysiology experts to help manage these conditions with medication or device therapy improves symptoms and mortality for patients with heart failure.”

Arrhythmias such as atrial fibrillation respond well to medications. More complex ventricular arrhythmias may be life threatening, and drugs do not always help. In these cases, it is important to implant defibrillators or pacemakers to circumvent potentially catastrophic events. Recurrent ventricular arrhythmias not stabilized by implanted devices may require treatment with ablation.

Long-term Management

Once patients are stable and on optimal medical and device therapy, routine follow-up office visits provide the necessary level of care for most patients. However, some stable patients may diverge from their treatment courses or develop worsening symptoms. When necessary, patients may be brought to the clinic for urgent outpatient management with intravenous medical therapy.

One of the key components of the C.O.R.E. Clinic is ensuring patients maintain a robust relationship with their primary care provider throughout the treatment process. According to Dr. Ernst, half of all patients admitted to the hospital due to congestive heart failure have at least five other major medical diagnoses. When patients work with their primary care provider to address other medical issues, it becomes easier to properly manage congestive heart failure.

Pursuing cooperative collaboration, preventive disease management and personalized relationships with patients allows C.O.R.E. Clinic providers to positively impact the lives of patients, even when they are faced with complex diagnoses. 

Assisting with End-of-life Decisions

Despite advances being made in the early diagnosis and management of the condition, there is ultimately no cure for heart failure. The role of the physician in heart failure management is to allow the patient to live a long, happy life with the condition — a commitment that includes broaching topics that may be uncomfortable, such as palliative and hospice care choices.

“End-of-life decisions can be difficult for patients with chronic, complex medical conditions,” says Eric Ernst, MD, FACC, cardiologist with University of Minnesota Health Heart Care and Medical Director of the University of Minnesota Health C.O.R.E. Clinic. “Patients have to decide what their wishes are, and we certainly respect that. At the C.O.R.E. Clinic, we work with families to fill out advance directives that allow patients to start these conversations.”

In Minnesota, advance directives (also known as health care directives) combine the living will and durable power of attorney for health care into a single document that appoints an agent to make healthcare decisions for the patient, leaves healthcare instructions within reasonable and legal medical practice, and details personal beliefs and wishes. Patients may also choose to use a Physician Orders for Life-Sustaining Treatment form, a legal document that communicates end-of-life wishes to medical personnel during an emergency.

When patients are ready to transition to palliative care but do not meet the requirements for hospice treatment, the outpatient palliative care program helps patients and families through what can be a difficult time. For patients who have been receiving interventional care for congestive heart failure, advanced heart failure may require re-evaluation of treatments and devices originally intended to improve longevity and quality of life. Implantable cardioverter defibrillators and mechanical heart pumps may no longer provide the same benefits, though the discomfort sometimes associated with these devices remains. Inpatient and home-based hospice programs allow families to receive necessary services when the time is right.

Those are the types of topics families and patients can discuss in-depth with team members at the C.O.R.E. Clinic. All members understand the sensitive nature of advanced heart failure and strive to act as a united resource during these difficult times.