Cardiovascular disease (CVD) remains the number one cause of mortality in the United States accounting for approximately 2,500 deaths per day despite significant advances in therapeutics over the last 40 years. There is building comprehension that cardiovascular disease is linked to other chronic conditions under the umbrella of cardiovascular-kidney-metabolic syndrome (CKM), resulting from the interactions between obesity, diabetes, chronic kidney disease, and cardiovascular disease. These disease processes act synergistically across the CKM syndrome, accelerating disease progression resulting in a more severe disease state.
The scale of the problem is unchecked. About a third of U.S. adults have at least three risk factors for CKM and 90% meet the criteria for Stage 1 CKM. Obesity is a fundamental cause—more than 40% of U.S. adults are obese, and that proportion is steadily increasing. At Monogram Health, 30% of patients carry the burden of 4 or more cardiovascular disease diagnoses (i.e., hypertension, ischemic heart disease, heart failure, atrial fibrillation, peripheral arterial disease, and cerebrovascular disease) —in addition to pulmonary disease (i.e., COPD, restrictive lung disease, obstructive sleep apnea, pulmonary hypertension), diabetes, thyroid disease, and chronic kidney disease. This overlap of chronic conditions is why Monogram’s unique model of in-home, holistic care for polychronic patients is critical.
Specialty Integration
CVD is not a disease of old age, but a disease associated with aging—it is cumulative. It is a result of years of accumulated damaging risk factors that are shared across the spectrum of polychronic conditions. All the multimorbidity that a patient is dealing with is interrelated, and a holistic, comprehensive approach is necessary to provide optimal care. For our patients, it is crucial that cardiovascular health be assessed in every patient, regardless of their symptoms or diagnosis. For example, patients with chronic kidney disease (CKD) have an elevated cardiovascular risk and are significantly more likely to die from a cardiovascular complication like stroke or heart failure.
Integrating specialty care management into care plans can close gaps in care before they have a negative impact. As the Chief Cardiologist at Monogram, I collaborate with the Chief Pulmonologist and Chief Nephrologist daily about individual patients to produce a cross-disciplinary plan for them. For example, if one of our patients develops shortness of breath, we may need to treat their heart failure, but we also might need to simultaneously treat their COPD and monitor their kidney disease. We have demonstrated that if you do not treat these conditions together, outcomes will not improve.
In-Home Capabilities
Monogram Health’s model is based on in-home engagement with our patients—we bring treatment and care to them and provide a comprehensive assessment of the patient, which includes:
- An extensive history and a thorough examination that goes well beyond what you would get in a physician’s office (where the average visit lasts just 18 minutes).
- A review of previous care instructions.
- A comprehensive medication review and reconciliation from our team of pharmacists, which involves collaboration between specialties and often helps avoid therapeutic competition and contraindication.
- A consultation with our team of dietitians.
- An assessment of a patient’s physical limitations and daily living conditions to better identify any social determinants of health (SDOH) issues.
- A comprehensive management plan focused on improving heart disease symptoms and outcomes in the context of their polychronic conditions.
A thorough cardiovascular examination is baked into every care plan, including blood work, and if a patient needs something like an EKG, echocardiogram, MRI, CT, or stress test, we make those referrals and will collaborate with the patient’s community cardiologist to coordinate any changes to their care plan, or to provide care beyond the scope of services provided by our own cardiology trained advanced practice providers (APPs). If the patient does not have a local cardiologist, Monogram Health can fill that void. Our care teams are comprised of local APPs – supported by order sets and protocols created by our Cardiology chief – who live in these communities and who understand regional, religious, and cultural nuances as well as local SDOH issues.
Early Intervention and Palliative Care
A key element of our model in terms of cardiovascular health is proactively addressing risk factors. For example, for a patient with CKD, our heart failure protocols look for Stage A – or “at risk for developing” heart failure. If we identify and reduce those risk factors, we might prevent that patient from developing heart failure in the first place—for example, lowering systolic blood pressure can reduce incident heart failure by as much as 38%. At Monogram, 78% of our enrolled patients have controlled blood pressure. Similarly, each stage of CKM syndrome represents an opportunity to intervene and prevent the development of polychronic conditions in the future by treating core causes in the present.
Equally important is how we weave palliative care into cardiovascular treatment. Palliative care is not something introduced only at the end of life—palliative care involves improving symptoms and quality of life; every patient should receive a patient-centered “goals of care plan” irrespective of the stage of their disease. Then, Monogram’s Chief Palliative Care Physician will weigh in on how to manage a patient, often talking with the patient and their family to determine what the patient wants and what is important to them. Cardiovascular diseases often generate a great deal of anxiety and fear. If you are an adult child and trying to make educated decisions for your parents about their treatment, care, and/or quality of life, it can feel overwhelming. However, if your parents have discussed their wishes prior to an emergency, those decisions become much easier.
Outcomes
By integrating cardiovascular care into every patient interaction and offering a comprehensive, in-home approach that does not focus solely on one organ, symptom, or condition at a time, Monogram has achieved impressive results:
- Our patients have 52% fewer emergency room visits and 44% fewer hospital admissions, not to mention fewer readmissions as well.
- Providing multi-specialty services also reduces the number of visits to a physician’s office, preventing what Dr. Shaminder Gupta termed “specialist fatigue” in the introductory article to this series (article here).
- All our patients undergo a comprehensive medication review, which has led to a reduction in adverse events from high-risk medications for many of our patients.
At Monogram, our model is efficiently and effectively suited to care for patients with overlapping polychronic conditions because we see—and look for—the “big picture.” We diagnose, treat, and prescribe based on a patient’s whole health (including pharmacological, behavioral, and SDOH) moving the delivery of care far beyond one organ, one condition, or one treatment. Our patients are healthier—and happier—as a result.
Learn more about Monogram Health here.
The post Fighting the Number One Cause of Death by Approaching Polychronic Conditions Holistically appeared first on Becker's Hospital Review | Healthcare News & Analysis.
Source: Read Original Article
