PROPOSAL TITLE: UCSF Advanced Heart Failure Comprehensive Care Center (AHF CCC) Ambulatory IV Diuretic Clinic to reduce heart failure admissions, readmissions and improve patient outcomes and  throughput at UCSF Health

PROJECT LEAD(S): Amanda Browne, NP, MBA & Nimi Tarango, NP

EXECUTIVE SPONSOR:  Liviu Klein, MD

ABSTRACT – Currently at UCSF Health, heart failure (HF) patients who are volume overloaded and resistant to oral diuretics only have the option to be admitted to the hospital for medical management of their decompensated heart failure. Hospital admissions and readmissions are costly and moreover, increase patient morbidity and mortality (Verma et al., 2021).  UCSF Medical Center’s patient census is persistently at maximum capacity and has daily challenges accommodating patients. Multiple studies have shown cost savings and admission prevention with the use of IV diuretic clinics. Given the high census at UCSF and need for acute care beds, we propose the creation of an Advanced Heart Failure IV diuretic clinic: to reduce hospital admissions for patients with acute heart failure associated with volume overload; to reduce costs associated with HF hospitalizations by preventing index, as well as HF readmissions; to reduce morbidity and mortality; and improve overall care and management of HF patients.

Proposed initiative: The Advanced Heart Failure Comprehensive Care Center (AHF CCC) proposes the creation of an Advanced Heart Failure IV diuretic clinic. The clinic will be located at 400 Parnassus Avenue, 5th floor Heart & Vascular Center expansion clinic.  The clinic is already licensed for medication administration. There exists a treatment Room with 2 treatment beds-already embedded in the clinic (previously used for allergy testing). Supported by Administrative Director, Brenda Mar, who has allocated these beds for purposes of an IV Diuretic clinic.  Referring providers from across the health system will have a direct phone # for seamless scheduling with next day appointments available. The clinic will service patients with heart failure and volume overload (VOL) from the following settings: (1) Outpatient: All patients with a diagnosis of heart failure who are failing oral diuretics despite increasing doses. Patients can be referred to the IV Diuretic clinic for diuretic resistant heart failure; (2) Emergency Room & Clinical Decision Unit (CDU): Patients in the Emergency Room presenting with HF and volume overload who are hemodynamically stable. Patients may receive IV diuretic dosing in the ER and /or CDU with a discharge plan to be seen in the IV Diuretic clinic the following day for additional diuretic dosing. Of note: “The most common reason for rehospitalization following an ED encounter for IV diuresis was recurrent HF” (Jiang et al., 2024) (3) Acute Care: Patients who are hospitalized with HF and are nearing euvolemia can be discharged 1-2 days early and can be scheduled for appt with the IV Diuretic clinic the day following discharge for additional diuretic administration and plan to transition to PO diuretics under the care and management of AHF APP and MD team.

TEAM:

AHF Administrative Leadership: Amanda Browne MBA, NP, Administrative Director & Nimi Tarango, NP, Associate Administrative Director

AHF Attending MDs: Mandar Aras, Richard Cheng, Teresa De Marco, Liviu Klein, Shweta Motiwala, & Marc Simon, as needed for APP consults.

AHF Pharmacists: Brandon Martinez & Jose Lazo

AHF APPs: Robin Fischer, Simran Grewal, & Yuri Nam

AHF RN coordinators: Maddy Cole, Jamie Lee, & Ceile Valerio

AHF Patient coordinators: Jailah Hawkes, Camille Hill, & Breeana Hill

ACC 5 Heart and Vascular clinic medical assistants

PROBLEM: Heart failure (HF) is a highly prevalent medical condition in the United States, currently affecting 6.2 million patients with an estimated increase to 8.5 million by 2030. HF is the number one discharge diagnosis for patients over the age of 65. A Medicare analysis estimated that annual costs for worsening chronic HF is between $9.3 billion and $17 billion. Furthermore, HF was the most common reason for rehospitalization, accounting for up to 8.6% of all 30-day hospital readmissions. (Jiang et al., 2024). 

Readmissions /Cost Savings with IV Diuretic clinic: There are several studies that show the benefit of ambulatory IV diuretic clinics impacting readmission rates and show financial benefit to hospitals.

• A recent retrospective metanalysis study published in Journal of Cardiac Failure looking at Medicare patients (requiring IV diuretics) from 2011 – 2018 found that patients treated in observation and outpatient settings had lower 30-day mortality rates and decreased 30-day total cost compared to patients treated in inpatient settings for IV diuresis. (Jiang et al., 2024).
• Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.
• It also noted that patients treated in the emergency room and discharged had higher mortality rates, thus emphasizing the need to treat these patients in an outpatient setting. 
• Patients who received IV diuresis in the outpatient setting had a 47% decreased 30-day mortality rate, as compared to those treated in the inpatient setting. (Jiang et al., 2024
• Amand et al. showed that ambulatory IV diuretic clinic was associated with a decreased risk of all cause rehospitalization, heart failure hospitalization or death over 180 days of follow up when compared to patients who had a 48-hour observational hospitalization during the 6-months post index heart failure admission (St Amand et al., 2020).
• In another study, when comparing inpatient diuresis to outpatient IV diuretic clinic there was no significant difference in amount of diuresis per day, adverse outcomes, 30-90-day readmissions or deaths; however, there was a significantly lower cost for the outpatient diuresis group compared to the inpatient group ($839.4 vs $9,895.7, p=<0.001) (Halatchev et al., 2021)
• Finally, Nair et al. did a retrospective analysis that showed 30-day readmission rates of 6-9% in the group receiving IV diuretics in an ambulatory setting compared to the national average of 25%. They also showed an average cost savings of $681,986 per year to the hospital
• Both index and readmission HF Hospitalizations at UCSF are costly for UCSF, resulting in lost revenue.  An outpatient IV diuretic clinic at UCSF Parnassus could offer patients close follow up and continued outpatient treatment for their heart failure symptoms helping to reduce readmission rates.
  • The financial burden for heart failure admission in fiscal year 2023 at UCSF was $16,719 direct cost per patient for the index hospitalization.
  • In FY 23 an index HF hospitalization for non-ICU admission at UCSF Health cost the health system $16,719 and a HF readmission costs the health system $26,030 with an average LOS of 8.1 days. Net income for these hospitalizations is ($3254) and ($8373) respectively.
  • Furthermore, the Medicare readmission reduction program implemented in 2012 penalizes hospitals for readmission within 30 days for conditions including HF, which results in a 3% penalty for HF readmissions that occur within 30 days of discharge, providing additional incentives.

• At UCSF Health, approximately 60% of all admissions on the Cardiology Service are those patients with a primary diagnosis of HF.
• In FY ’23 average LOS for a non-ICU HF admission is 5.3 days and readmission is 8.1 days.
• In FY ’23, there were 61 HF readmissions, resulting in a cost to the health system of  $1,587, 829.
• As shown in the literature, an IV Diuretic clinic has been shown to prevent both index and HF readmissions. 
• A 20% reduction in readmissions with IV diuretic clinic at UCSF would result in a savings to the health system of $317,565. 
• Preventing HF admissions and readmissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in reduced costs, increased bed capacity, improved throughput, and reduced morbidity and mortality in this population.
• Optimal Timing for this initiative: The growth and expansion of the AHF CCC since 2021 has allowed for increased patient capacity with increased staffing to accommodate the tremendous growth of the HF patient population.  Furthermore, with the expansion space of the HVC clinic at 400 Parnassus ACC 5 available, with a pre-existing treatment room and licensing for medication administration, the timing, and conditions to safely operate an IV Diuretic clinic with specially trained HF clinical staff could not be more optimal.

TARGET: An IV diuretic clinic at UCSF Parnassus ACC 5 clinic will result in avoidable admissions and readmissions for HF, as well as allow for ER and CDU pending admission to be diverted to the outpatient IV Diuretic clinic for management of acute heart failure in hemodynamically stable patients. The expected opening of the IV Diuretic Clinic will coincide with the approval by the California Department of Public Health (CDPH) of the expanded ACC 5, 400 Parnassus HVC clinic, expected mid-2024. A conservative estimate for a goal that the IV diuretic clinic would achieve within 1 year of operation would be prevention of approximately 20% of HF readmissions-this would result in a savings to the health system of $317,565. Furthermore, preventing index admissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in reduced costs, increased bed capacity, improved throughput, and reduced morbidity and mortality in this population. Currently patients are referred to the AHF CCC by provider referral. However, the IV Diuretic clinic will Improve access to specialized AHF CCC care, by expanding the reach and care to a broader population of patients that are currently not serviced by the AHF CCC. This will increase access for vulnerable populations by expedited referrals through ER, CDU, inpatient, as well as outpatient referrals from no-AHF providers.

GAPS:  Heart failure (HF) is a highly prevalent medical condition in the United States, currently affecting 6.2 million patients with an estimated increase to 8.5 million by 2030. HF is the number one discharge diagnosis for patients over the age of 65. A Medicare analysis estimated that annual costs for worsening chronic HF is between $9.3 billion and $17 billion. Furthermore, HF was the most common reason for rehospitalization, accounting for up to 8.6% of 30-day hospital readmissions. (Jiang et al., 2024)

Many large academic quaternary health systems across the United States have ambulatory IV Diuretic clinics.  The absence of such a clinic at UCSF is a major gap in the otherwise comprehensive heart failure care that we provide to this patient population, and sorely needed. Prior to the creation of the AHF CCC in late 2021, resources, staffing, and administrative oversight for HF patients was spread thin across multiple service lines, making this endeavor a challenge to launch and provide dedicated management and support for. With the creation of the AHF CCC, HF patient care is now housed under one umbrella within the AHF CCC with dedicated staff and administrative leadership. The AHF CCC treats patients from initial HF diagnosis to the time that advanced therapies, including heart transplant and left ventricular assist device (LVAD) may be needed, as well through palliative and end of life care.

INTERVENTION:

• The IV Diuretic Clinic will operate at 400 Parnassus, ACC 5 Cardiology expansion clinic. 5 days a week M-F, from 8am to 5pm.
• The clinic will operate 2 beds within the treatment room and accommodate up to 4 patients per day, over four 4-hour clinic appointments daily, or allow for 8-hour appointments as needed, based on patient condition. The clinic is already licensed for medication administration. There exists a treatment Room with 2 treatment beds-already embedded in the clinic (previously used for allergy testing). Supported by Administrative Director of Ambulatory Cardiology, Brenda Mar, who has allocated these beds for purposes of an IV Diuretic clinic. 
• The room will need to have scales and blood pressure monitoring equipment
• There will need to be a pyxis or locked cabinet to house IV diuretics (furosemide and bumetanide) as well as oral electrolyte supplements.
• There will need to be IV access equipment
• IV Fluids in case needed for over diuresis
• Sensible Medial RedS Vest (these are technology that allow for assessment of VOL in patients with HF in a non-invasive way). These items are already approved for the AHF CCC budget and will not incur additional costs.
• It will be staffed by experienced HF APPs, RNs, and PharmDs. These are existing staff within he AHF CCC. No additional staff are needed for this initiative.
• Referring providers from across the health system will have a direct phone # for seamless scheduling with next day appointments available.
• The clinic will service patients with heart failure and volume overload (VOL) from the following settings:
  • (1) Outpatient: All patients with a diagnosis of heart failure who are failing oral diuretics despite increasing doses. Patients can be referred to the IV Diuretic clinic for diuretic resistant heart failure
  • (2) Emergency Room & Clinical Decision Unit (CDU): Patients in the Emergency Room presenting with HF and volume overload who are hemodynamically stable. Patients may receive IV diuretic dosing in the ER and /or CDU with a discharge plan to be seen in the IV Diuretic clinic the following day for additional diuretic dosing.
  • (3) Acute Care: Patients who are hospitalized with HF and are nearing euvolemia can be discharged 1-2 days early and can be scheduled for appt with the IV Diuretic clinic the day following discharge for additional diuretic administration and plan to transition to PO diuretics under the care and management of AHF APP and MD team.
  • The day prior to the patient’s appt, the AHF APP will review the referral, review the chart and patient’s medical history and current HF status.
  • The morning of the appt the AHF APP will clinically assess the patient and order the appropriate IV diuretic dose.
  • In collaboration with the APP, the AHF RN would monitor the patient during treatment and following treatment for 1-3 hours post diuretic administration and perform heart failure education as needed and then discharge the patient home.
  • AHF PharmDs to monitor medication inventory. AHF CCC Patient Coordinator to assist with securing follow up appts with AHF CCC if needed, or PCP or cardiologist for patients to optimize transition from AHF CCC IV diuretic clinic.
  • We anticipate there may be a need for ambulatory SW or case manager to assist with transportation to /from clinic, and other psychosocial needs as they arise.
  • In collaboration with the AHF CCC IT data analyst and the UCSF finance department, we will observe admission, readmission and LOS data for HF patients following launch of the IV diuretic clinic to observe for changes in admissions, readmissions, and LOS.  
    • We will also conduct qualitative surveys of the Emergency Department provider staff, as well as and General Cardiology providers at baseline and again at 6 and 12 months following the opening of the IV diuretic clinic to evaluate access, ease of referral, efficacy of treatment, transitions from IV diuretic clinic back to primary care provider or primary cardiologist or other service provider. 
    • Adverse outcomes that could occur as a results of IV diuretic clinic may be electrolyte disturbances and changes in renal function within patients following diuresis. There may be alterations in blood pressure (hypotension) with associated diuresis.  Close monitoring for 1-4 hours (or more if needed) will be provided to each patient following treatment to observe for any untoward side effects. 
    • Repeat STAT labs will be performed on the first floor lab at 400 Parnassus with anticipated results in 1 hour to allow IV diuretic clinical nursing and APP staff time to review results and make recommendations to patients on the same day of treatment.

PROPOSED EHR MODIFICATIONS: (1) Flowsheet for ambulatory Apex to document initial weight, daily weight during treatment period, and goal dry weight, dose of diuretic, BP (2) Outpatient SmartSet for IV diuretic order and monitoring (3) creation of reports to track outcomes data i.e. volumes, weight loss, adverse events, readmissions (4) Establish billing capabilities

UPFRONT COSTS:

• Baseline Costs
  • Pyxis MedStation ES 2-Draw        $22,999.00
  • GE Critikon Dinamap V100  x 2    $2500.00
  • Initial IV Supplies (including IV starter kit, tubing, fluids etc)           $2000.00
  • Medication Costs: Total $10,800.00
    • IV Furosemide
    • IV Bumetanide
    • PO Potassium
    • PO Magnesium
    • Metolazone
    • Midodrine          
    • Total Start up Costs $38,299

RETURN ON INVESTMENT (ROI)

• A recent retrospective study published in Journal of Cardiac Failure looking at Medicare patients (requiring IV diuretics) from 2011 – 2018 found that patients treated in observation and outpatient settings had lower 30-day mortality rates and decreased 30-day total cost compared to patients treated in inpatient settings for IV diuresis. (Jiang et al., 2024)
• Metanalysis Results by Jiang, et al. 2024 demonstrated that the average estimated for outpatient IV diuretic clinic cost for Index Clinic Visit Cost was $734; Estimated outpatient index clinic visit and total 30 day followup was $5977.
• Estimated Savings of IV Diuretic Clinic VS. Acute care hospitalization $7005 per patient
• At UCSF Health, in FY ’23, readmission rates were 18% with an average LOS of 8,1 hospital days
  • In FY ’23, there were 61 HF readmissions, resulting in a cost to the health system of  $1,587, 829.  As shown in the literature, an IV Diuretic clinic has been shown to prevent both index and HF readmissions. 
  • A 20% reduction in readmissions with IV diuretic clinic at UCSF would result in a savings to the health system of $317,565. 
  • Furthermore, preventing HF admissions and readmissions from the outpatient setting; preventing ER and CDU patients from hospitalization; as well as facilitating early discharges for suitable inpatients with the newly proposed AHF CCC IV Diuretic Clinic, will result in:
    • reduced costs overall. Total 30 day costs were lowest with treatment in the outpatient and observation settings, at $5977 and $7123, respectively, compared to the average cost of $10,312 in the ED setting (Jiang et al., 2024)
    • increased bed capacity for other patients that require acute care
    • improved throughput with the ability to discharge appropriate HF patients early to the IV diuretic clinic
    •  reduced morbidity and mortality in this population. Patients who received IV diuresis in the outpatient setting had a 47% decreased 30-day mortality rate, respectively, as compared to those treated in the inpatient setting. (Jiang et al., 2024). It also noted that patients treated in the emergency room and discharged had higher mortality rates, thus emphasizing the need to treat these patients in an outpatient setting. 
    • Added Benefit: increased adherence to Guideline Directed Medical Management
      • Guideline directed medical therapy (GDMT) is shown to reduce morbidity, mortality, hospitalization and re-hospitalization for HF. There is a significant lack of usage of GDMT among HF patients. Quadruple medical GDMT therapy for HFrEF is estimated to reduce the risk of death by 73% over 2 years. (Patolia et al., 2023)
      • The IV Diuretic clinic staffed by an AHF specialized team will help to increase prescribing of GDMT these life-saving therapies, thereby further reducing rehospitalization and reducing morbidity and mortality. (Heidenreich et al., 2022)

SUSTAINABILITY:  

• If successful, this intervention will be sustained beyond the funding year as the upfront costs for equipment will be the primary initiation costs.
• Staffing for the clinic will be provided by current AHF CCC APPs, RNs, PharmDs, PCs, and HVC medical assistants. No new staff are required to sustain this clinic. Additional labor resources will be requested as needed based on the ambulatory IV diuretic clinic success  and need to expand services. If successful, future consideration can be given to replicate an IV diuretic clinic at Mission Bay Cardiovascular Care Center to serve a larger number of patients across San Francisco.
• We anticipate we will be able to bill insurance
• Budget:
• Monthly Order
  • IV Lasix  $2368.00
  • IV Bumex             $1165.00
  • Quarterly Order
    • IV Supplies          $2000.00
    • PO Potassium (20MEq & 40MEq) Solution             $3624.00
    • PO Magnesium $26.40
    • PO Metolazone $280.00
    • PO Midodrine    $777.60