A Population Health Approach to Managing Heart Failure - Episode 17

Navigating Multidisciplinary HF Treatment With Multiple Comorbidities

Multiple comorbidities lead to an emphasis on multidisciplinary care management when determining the most effective HF treatment strategies.

Ryan Haumschild, PharmD, MS, MBA: Dr Uppal, when we talk about increased cost, there’s management with all these patient types. We’ve talked a lot about comorbid patients, and you’ve done a great job highlighting the importance of an interdisciplinary team when we’re talking about the treatments. As you start to look at your patients with multiple chronic conditions and the propensity for patients with heart failure to present with these multiple comorbidities, how are you allocating the resources to better deal with these patients and to have better oversight, whether it be case management or making sure they’re taking their medications [appropriately]? Besides identifying them, how are you addressing patients who are at risk for these multiple comorbidities with the limited resources that you have among your team?

Rohit Uppal, MD, MBA, SFH: As a hospitalist, one of our core competencies is the skill set of matching the intensity of the patient’s medical illness and the amount of social support they have with the appropriate resources. As you mentioned, it’s always a team effort. One of the key tactics is to have some level of interdisciplinary communication. For hospitalists, we lead daily multidisciplinary rounds where we have all of the disciplines having a conversation together for each patient and determining the appropriate resources based on all of the different inputs from those disciplines. It’s a complex interplay of the severity of their CHF [congestive heart failure], the burden of their comorbidities, and the many social determinants of health that will impact their eventual outcomes.

Some EMRs [electronic medical records] have some risk scoring tools embedded, such as the LACE [length of stay, acute/emergent admission, Charlson Comorbidity Index score, emergency department visits in previous 6 months] tool or the LACE+ tool, which can help risk stratify hospitalized patients. The reality is that most of these patients with CHF score in a high-risk category anyway, so it isn’t always helpful in this population. Then there’s the issue of comorbidities and multiple comorbidities. For hospitalists, this is the rule more than the exception. The majority of our patients have multiple comorbidities, which complicates care. They only get worse with the aging of the population and the increased life expectancies we’re seeing in patients with CHF. We’re only going to see that increase.

Often in these patients, the challenge is that we underutilize effective treatments out of concern for safety or challenges with patient adherence. That’s where you need the care managers, the pharmacist, and home visits to help promote adherence. If there are challenges with implementing medications in the hospital, it’s important to have clear communication across transitions, where we make sure the ball is handed off to the next clinician.

The other thing I’ll note is to not overlook readmissions in this population. They’re often related to comorbidities rather than CHF. We have to focus on those comorbidities as well. It comes down to having all of those multidisciplinary elements, bringing all of that together to bear, and having the collaboration not just with those interdisciplinary elements but also the other specialists, cardiologists, and others. Those become even more important.

Transcript edited for clarity.