Congestive heart failure impacts a large chunk of the nursing home population and is a particularly difficult condition to manage, often resulting in a high number of rehospitalizations. And yet while nursing home providers look to promising new solutions, the efforts to put them into widespread use are stymied by staffing problems.
More than 6 million people over the age of 65 are diagnosed with heart failure, and CHF is estimated to impact anywhere from 20% to roughly 40% of the skilled nursing facility population. The issue is further compounded by the fact that rehospitalization rates for these patients in SNFs range anywhere from 27% to 43%, mainly due to comorbid conditions such as diabetes, kidney disease and lung disease.
Given these dire statistics, medical experts at SNFs are always grappling with new ways to counter the problem. These solutions include wearable vests, implanted devices that monitor a patient’s fluid, artificial intelligence-enabled weight checks, improved communication protocols for sharing real-time clinical data as well as therapeutic medicines.
However, many of these CHF management methods are time and labor intensive, and all require close monitoring and follow up. And so managing disease for this highly acute population group often falls back on traditional methods – ones that rely on education and training, according to clinicians working with SNFs.
Nicole Orr, M.D., a cardiologist affiliated with Post-Acute Cardiology Care (PACC), told SNN that the care of CHF patients has recently been complicated by lack of staff during recovery from the Covid pandemic.
“Facilities that are well staffed might have nurse practitioners who have expertise that enable them to do a little bit more of these sophisticated cardiac interventions. But many facilities in the post-Covid SNF world are still in this staffing shortage … the workforce is really [too] overwhelmed,” Orr said.
Through PACC, an independent medical practice which provides specialized cardiovascular consultation to high-risk patients residing in skilled nursing facilities (SNF), Orr is on a mission to reduce rehospitalizations for SNF patients with cardiovascular disease.
“So how do we best prevent heart failure in SNFs now? It’s a fine line between taking on something novel and just doing really good clinical medicine,” Orr said.
In Orr’s engagement with medical directors at nursing homes across the nation, she has received feedback that labor shortages have stunted recent innovations in the management of CHF, she said. But she is hopeful that things will improve.
“There’s still a lot of policy changes that are needed to improve capacities for SNFs to be more innovative,” Orr said.
CHF innovations limited by staffing shortages
Promising innovations have taken a back seat, including the use of a wearable vest – the ReDS Vest – a non-invasive tool for the measurement of lung fluid that uses radar sensors.
Doctors who have used wearable vests tout improvements in CHF disease management and the time involved.
Zachary Palace, M.D., medical director of the Hebrew Home at Riverdale in New York, who is all for these technology-enabled tools, has used the wearable vests with his CHF patients to great success.
“Part of what we were constantly doing is identifying, incorporating technology into clinical practice to be able to improve outcomes. So one area of innovation that we’ve been engaging in now for about two years has been a device called the ReDS vest,” Palace said. “It’s a type of a device that [is] just placed over the chest and actually measures total water volume. So it’s completely revolutionized the way we’ve been able to manage CHF patients,” he said.
Traditionally, CHF management has always been a “reactive approach,” Palace said. And, CHF patients collect fluid in their lungs, which causes them to put on weight and become short of breath. The usual response to counter CHF is to administer diuretics to get rid of the excess fluid. With the wearable vest that measures the fluid in lungs, the removal of excess fluid can be more precise – and less time consuming.
“We’ll check them twice a week or so, and based on those numbers, tweak up or tweak down the diuretics and adjust their diuretic medications and prevent CHF exacerbations before they occur,” Palace said. “So we’ve been able to show significant reductions in hospitalizations for patients with CHF using that technology.”
That said, it’s unclear if the wearable vest technology is in widespread use in facilities.
“It requires dedicated personnel that would have the training and time permission to monitor,” Orr said.
Another solution such as the CardioMEMS system, which wirelessly measures and monitors pulmonary artery pressure and heart rate through an implanted device, can make a difference, and yet it has also seen limited use in SNF patients, according to Orr.
“I’ve seen success with patients who have a CardioMEMS that is implanted in the hospital by their cardiologist,” Orr said.
Bedside assessments of volume status can be tricky in this demographic of complex patients, and goes beyond simple weight checks, and can be misleading and ultimately time consuming as well. CardioMEMS allows real-time remote monitoring by cardiologists or trained nurse practitioners. Early changes in pulmonary artery pressures – an early indicator of worsening heart failure – are detected using the device.
“CardioMEMS really does take off the burden from overwhelmed staff on doing such difficult volume assessments,” she said. Orr has observed the use of these in roughly 25 patients in the last two years in the facilities that she oversees.
Moreover, the lines of communication can get blurred but are key to managing CHF. Innovations on this front include nursing home operator The Allure Group’s protocol called “Hearts in Motion.” The protocol operates through a remote cardiac monitoring program that ensures that teams are trained to correctly monitor data such as weight changes, renal function and other indicators of potential health risks, according to information on the organization’s website. If one of these factors changes significantly, the cardiologist receives an immediate automated alert. To monitor slower long-term changes, the teams meet weekly to discuss the patient’s overall health. In a test group of 152 patients in facilities that partner with the organization in the New York area, its protocol resulted in a decrease in hospital admissions from 31% to 7%, the company said.
“The success behind our Hearts in Motion program has been years in the making, with much trial and error,” Joel Landau, chairman of The Allure Group, told SNN. The organization initially piloted the program at its Bedford Center location, but it has since been rolled out across its six-facility network, Landau said.
“When like-minded partners are in place, the time and effort spent collaborating are well worth the outcomes for our residents,” Landau said.
Regardless of the innovation, many of these solutions are aimed at tackling communication issues between clinical staff in the end, and require training and investment.
Short of these tools, Orr suggests that the best way to enhance CHF treatment is education on the management and use of medicines. These drugs include Sacubitril/Valsartan, and SGLT2 inhibitors, initially a medication for diabetes, but now a cornerstone therapy for all phenotypes of heart failure.
Educating clinical staff
Educating SNF on the use of therapeutic drugs has not only improved hospital readmissions, but morbidity and mortality outcomes, Orr said, noting, “It is one of the best interventions that we can do if we can train the workforce on the need for upfront use of these therapeutics.”
Moreover, these therapeutics don’t need an outpatient cardiologist, which makes them very useful, although it does require educating clinical staff at SNFs.
“And so I went straight to help improve education across the SNF landscape in Connecticut, and I found that that has been one of the biggest tools in my armamentarium,” she said.
As she conducts trainings, Orr does Q&As with staff and likes to incorporate case studies of patients.
Orr has conducted such educational in-service programs at SNFs in the Northeast region with her organization partners.
And while there is a high success rate overall in health outcomes due to these educational meetings, reducing readmissions for CHF patients can be another matter.
“Most of the patients that come into SNFs don’t just have heart failure. They have multiple comorbidities. And so managing their heart failure is just one piece of the puzzle in preventing readmissions,” Orr said.
In the end, Orr says, education of the staff is the best kind of innovation, adding she “can’t emphasize that enough.”
“I sound very old school [and] I’m all open to novel, interesting therapeutics and telemonitoring,” she said. “But the degree to which these are successful really still will depend on the education and also the resource availability in the SNF staffing, which is still a problem.”
Companies featured in this article:
Hebrew Home at Riverdale, Post-Acute Cardiology Care, The Allure Group
