Program monitors patients, provides specialized care

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Studies show that people with heart failure do better if they're part of a formal heart failure disease management program rather than regular medical care.

Today, we'll learn about Upstate's Heart Failure Clinic and how it works from nurse practitioner Kristin Ramella and nurse Sarah Bobenhausen, who's the clinical leader of the Heart Failure Clinic.

Welcome to "The Informed Patient," both of you.

Kristin Ramella, NP: Thank you very much for having us.

Sarah Bobenhausen: Thank you.

Host Amber Smith: Let's start with an explanation. Why is it important for the Heart Failure Clinic to exist?

Kristin Ramella, NP: Heart failure affects millions of Americans every year. It is very, very difficult to manage, as it is a continually dose-adjusted, symptom-changing disease process.

Typically, one set of medications does not work for the same two people, and also the same person might need frequent medication dose adjustments in order to effectively treat them, to get them to feel well.

The Heart Failure Clinic is used for patients that need frequent follow-up, and really our main goal is to keep people out of the hospital.

We do a lot of interventions in the office, particularly for that reason. If someone's having symptoms, and they need some urgent help, but maybe they don't need to be admitted to the hospital yet, our main goal is to do some things in the clinic, adjust their medications, give them IV medicine, anything we can do to keep them out of the hospital.

There's also a big improvement in mortality and patient satisfaction when they have a good rapport with the clinic staff. We know them well. We know what works for them, what doesn't work for them, and they are able to come to us and share in that decision-making process.

Host Amber Smith: Do all hospitals have heart failure clinics?

Sarah Bobenhausen: No. There is another local hospital that offers some limited services, but Upstate is the only hospital around in Syracuse that gives more of the intense therapy. We give IV push medications, IV drip medications. We give quite a few different medications.

Host Amber Smith: Are the heart failure clinics meant for people who have been diagnosed with heart failure, or are they people who are in danger of developing heart failure?

Sarah Bobenhausen: The Heart Failure Clinic sees patients who have already been diagnosed with heart failure.

Host Amber Smith: Let's talk about what exactly heart failure is, because when you look at it, heart failure, it sounds like the heart has stopped, but that's not necessarily what's going on, right?

Kristin Ramella, NP: Heart failure is a very fancy term for saying that the heart is not pumping well enough to give blood to the body.

There are particularly two forms of heart failure that we talk about. One is heart failure with reduced ejection fraction, or there's inability of the heart to pump enough blood to feed the body. The other form is heart failure with preserved ejection fraction. That is when the heart has a difficult time relaxing to fill with blood, so there is not appropriate amount of blood that's distributed to the body in that way.

There are very particular treatments for those types of heart failure, and underneath those categories of heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, there are many reasons that can contribute to that diagnosis.

For example, when the ejection fraction is reduced or that pumping action is weak, we look at: Was there a heart attack? That's something we need to look into immediately because the patient may qualify for emergent intervention that can fix that reduced ejection fraction. If that is not the case, then we look into other alternatives.

Is there an arrhythmia or an electrical problem with the heart that's causing the heart muscle to work harder?

Is there an autoimmune disorder? Are there other contributing factors? Drugs and alcohol is another big one that we tend to see, in our population in this area.

Then when you're looking at heart failure with preserved ejection fraction, hypertension or high blood pressure is a very, very highly linked, other diagnosis that leads to that type of heart failure.

Other forms can be sleep apnea. We have patients that are obese, with diabetes. Those tend to lead towards that heart failure with preserved ejection fraction.

Host Amber Smith: So it sounds like you have a wide variety of patients, even if they all have the same diagnosis, heart failure, but it sounds like they all have a lot of different things potentially happening.

Kristin Ramella, NP: Yes. We see anywhere from 18-year-olds all the way up to even 90-year-olds who have heart failure, and the underlying causes of those vary widely.

Host Amber Smith: How many people are enrolled in the Heart Failure Clinic at Upstate?

Sarah Bobenhausen: So we see, on average, about 80 visits per month. In October we had 79 visits, and out of those 79 visits, there were 37 different patients: 28 of those visits were acute visits, 36 of those were chronic visits. We see patients that were admitted in the hospital within seven days of their discharge for heart failure. It varies every month how many patients we see. It really depends on the need.

Host Amber Smith: I was going to ask how often patients have appointments, but you just answered that. It kind of varies, depending.

Now, are appointments at the clinic paid for by Medicare or other insurances?

Kristin Ramella, NP: Yes, the Heart Failure Clinic appointments are considered a nurse visit, even though a provider is there to oversee it and to determine what the course of action is or what the treatment plan is going to be.

There is no copay typically for those visits, either, because they're billed as a nurse visit, and insurance will cover those visits as well. It's not an out-of-pocket expense. To piggyback off what Sarah was mentioning about the appointments, it really does depend on the patient. So, typically, if we see someone who's newly diagnosed. They will have appointments almost once a week for the first two, three, four weeks, until we can get their medical therapy or their medications, ideally, at the right doses. And there's also a lot of education that goes into a newly diagnosed heart failure patient.

Typically, they're taking two to maybe three medications a day. And then once you earn that diagnosis of heart failure, your medication list goes from that two to three, to five or six or seven because it requires multiple medications, each doing something different to treat that heart muscle. That could be a very tough adjustment for patients and families and a lot of the Heart Failure Clinic visits, not only are we assessing their heart rate, their blood pressure, we're also doing a lot of education. How is your diet? How is your salt intake? How are you doing with your medications? Do we need assistance in getting your medications? Is there a better way that we can help you organize your medication, so it's easy for you to take?

So it's really a holistic approach to treating the patient, during those clinic visits. And then once it's a patient that gets established, we know them very well, they've been coming for several months, then some patients come for maintenance therapy, where they need an IV dose of medication once a month, once a week. Or there's other times where we have patients that we know that call us up and say, "Hey, I'm not feeling well. Can I come in?" And we get those patients in to be seen, and we get them treatment again, with our goal being to keep them out of the hospital.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with nurse Sarah Bobenhausen. She and nurse practitioner Kristin Ramella both care for patients in Upstate's Heart Failure Clinic.

Now, I'd like to have you walk us through what a brand-new patient might experience coming for their first visit. Is the Heart Failure Clinic in the hospital proper?

Sarah Bobenhausen: No, the Heart Failure Clinic is located at 90 Presidential Plaza, at UHCC (University Health Care Center). We are located in the Upstate cardiology office. It's its own clinic within the cardiology office.

Host Amber Smith: So what would be included in the first visit?

Kristin Ramella, NP: Typically, if the patient is newly diagnosed, and they're coming from the hospital as a hospital discharge, ideally they would see a provider in the office, whether it be myself as a nurse practitioner, a PA ( physician assistant), or one of the physicians in the office.

And then we would have them talk about the diagnosis, assess their medications, and then we would send them, oftentimes that same visit, right over to Sarah in the Heart Failure Clinic to continue that education piece. That's ideally what the first visit looks like.

Sometimes, if we don't have available appointments for patients soon enough after discharge, but we really want to get them in to get that education and to see if their medications are OK, they sometimes see Sarah in the clinic first, and the provider will stop in quick, make sure the patient's doing well, again, make any recommendations that are needed.

I always tell my patients when I see them after the hospital, especially, every visit will not be as long as the first visit. There's so much education involved, there's so much to absorb, so much talking, so much just to process everything that happened. And follow-up visits are typically not nearly as long as that first visit.

We also have, as far as exercise, we have a cardiac rehab program right here in our office.

If the patient is diagnosed with heart failure with a reduced ejection fraction, they are a candidate for receiving a cardiac rehab, which is a three-day-a-week program run by cardiac nurses. It's overseen by a cardiologist, and there are physical therapists. During the exercise program, a patient's heart is monitored to make sure that the program and what they're doing is OK for what their heart can handle. So the entire program is tailored to what that particular patient is able to do.

Host Amber Smith: So how long might a patient stay with the Heart Failure Clinic?

Kristin Ramella, NP: Forever. We really keep tabs on these patients forever. They call if they're not in an exacerbation, and they're still currently seeing a cardiologist, they call us when they are experiencing symptoms. And we bring them in. Sometimes we see patients once a week for years. Sometimes we see patients once or twice a year, but they never expire out of the program.

Host Amber Smith: Have you ever seen someone improve so much that they're no longer considered to be in heart failure?

Kristin Ramella, NP: Yes, we do often see that, particularly if the underlying cause is something that is reversible or that we can intervene on fast enough. For example, a lot of the drugs and alcohol that induce heart failure, if we can take away that substance and the reason why the heart is having to work so hard, if we catch it fast enough, the heart muscle can recover.

Some of the other things that heart failure can easily respond to is if there's an electrical problem with the heart, and the electrical activity is making the heart work harder. If we can fix that electrical problem, and again, if we can do it fast enough, that, with support of medication, we can get that heart failure to significantly improve.

Host Amber Smith: For the patients that are enrolled in the Heart Failure Clinic, what happens if they experience a problem, and they feel like they need to be seen, or they need to get some medical advice, are they able to get same-day appointments? And what happens if it's the evening or the weekend?

Sarah Bobenhausen: They absolutely are able to get same-day appointments. Many of my patients call me that morning and have an appointment that afternoon or the next day. Or, if they're seeing a provider in the clinic, the provider will bring them over right after the appointment. We are very flexible in the Heart Failure Clinic.

What if a patient who's part of the Heart Failure Clinic has an emergency? Do they go to the emergency room?

Kristin Ramella, NP: Sarah does a lot of what we call triage phone calls. So if a patient calls in, they explain their symptoms. If Sarah feels that they are safe enough to come to the office, to the Heart Failure Clinic, for treatment, we bring them in. If their symptoms over the phone sound severe enough, then we will recommend that they either call an ambulance or report directly to the emergency room.

Very often though, we are able to get patients in to avoid that hospital trip. That is one of our main goals, as we mentioned, to keep people out of the hospital.

And once patients get comfortable with what we do in the clinic, they will often catch those signs and symptoms at the earlier stages before it gets to the point where they're needing to go emergently to the hospital.

Host Amber Smith: To join the Heart Failure Clinic, people are referred by physicians, is that right?

Kristin Ramella, NP: Yeah. As of right now, we, are able to see any patient that has a cardiologist within the Upstate system. And typically, if it's a cardiologist that's not working directly in our office, they will reach out and request for their patient to be seen in the heart failure clinic, and Sarah and our other nurse, Patsy, are in frequent communication with them, as far as their treatment plan.

Host Amber Smith: Well, I want to thank both of you for making time to tell us about the Heart Failure Clinic.

Sarah Bobenhausen: Thank you. It was my pleasure.

Kristin Ramella, NP: Thank you, Amber. It was great speaking with you. Heart failure is something Sarah and I are very passionate about. We appreciate you taking the time.

Host Amber Smith: My guests have been nurse practitioner Kristin Ramella and nurse Sarah Bobenhausen, who's the clinical leader of the Heart Failure Clinic at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

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