Until recently, patients with congestive heart failure had one place to go for relief: a hospital.

“It can be a vicious cycle,” says Johns Hopkins cardiologist Nisha Gilotra. “Hospitals relieve the congestion by adjusting the patients’ medications. But they don’t cure the underlying condition. Thirty days after hospital discharge, a quarter to a third of those patients are back.”

Gilotra and colleagues have found a way to break that cycle. The Johns Hopkins Heart Failure Bridge Clinic, launched in 2012,  provides an outpatient setting for fluid removal, medication adjustments, exercise and nutrition guidance and education about when to go to the bridge clinic versus the hospital. The primary goal is to “bridge” patients safely from hospital to home. 

The result is better care at a lower cost, Gilotra says. Patients who go to the Heart Failure Bridge Clinic have 30-day readmission rates of 11%, compared with 25% for other congestive heart failure patients at Johns Hopkins, she says.    

“We focused on how best to serve these patients, first by identifying high-risk patients with high health care utilization, and then thinking about what resources we can provide that are cost-efficient, effective and accessible,” she says. “I think there’s a lot of potential to create similar setups for other disease states.”

Care Transformation

A catalyst for care transformation is the new Total Cost of Care Model for Maryland, which sets a limit on Medicare dollars spent per state resident, says Pamela Johnson, vice chair of quality and safety for the Department of Radiology and Radiological Sciences and a physician lead for the Johns Hopkins Health System High Value Care Committee. The pilot, a partnership between the state and the Centers for Medicare and Medicaid Services (CMS), creates incentives to provide cost-effective care across inpatient and outpatient settings.  

Many programs and performance improvement teams across the health system are working to improve quality, efficiency and affordability of care. For example, through the new Maryland Primary Care Program, JMAP is evolving to become a Care Transformation Organization (CTO). “Our CTO launched in 2019, and we are in the process of further building our capabilities to assist primary care practices in managing patients in need of more coordinated care,” notes Scott Berkowitz, JMAP executive director and senior medical director for accountable care.

Says Sarah Johnson Conway, medical director for accountable care: “As we look to reduce admissions (and readmissions) for these chronic conditions, we want to identify opportunities to optimize outpatient management and safely avoid unnecessary hospital-based care for our patients.”

Agile MD: Evidence-Based Decision Support

One important tool for improving care across the Johns Hopkins Health System is Agile MD, an evidence-based decision support tool championed by Johns Hopkins Hospital emergency providers. Agile MD works within the Epic electronic medical record system to place relevant best-practice guidance and information within easy reach of clinicians as they make decisions about testing and treatment. The content is created by Johns Hopkins physicians, advanced practice providers, nurses, pharmacists and residents, who synthesize the literature with their own clinical experience.

“We want clinicians to make decisions according to the evidence in a way that is at the same time tailored to the patient,” says Johnson. “We don’t want to completely standardize care, but do want to reduce variability that does not improve outcomes, especially when it involves overuse or underuse of tests and treatments.”

Guidelines for chronic obstructive pulmonary disease are among those being incorporated into Agile MD. Pulmonologist Robert Wise developed the guidelines with colleagues to diagnose patients early using a simple and inexpensive spirometry test. Clinicians then work to slow the disease’s progression through interventions including smoking cessation programs, reduced exposure to indoor and outdoor air pollution, and aggressive treatment of respiratory illnesses, he says.

Agile MD and programs that synergize emergency, ambulatory and hospital care are just a few of the ways Johns Hopkins can transform care. “We want people to know that we’re looking at opportunities to safely improve the quality and affordability of the care we deliver, and we’re coming together as a team to do it,” says Renee Demski, vice president of quality for The Johns Hopkins Hospital, Johns Hopkins Health System and the Armstrong Institute for Patient Safety and Quality.