Hello, my name is Ty Gluckman and I'm Medical Director of the Center for Cardiovascular Analytics, Research and Data Science at the Providence Heart Institute in Portland, Oregon. It's a real pleasure to be speaking with you today about the Patient Navigator Program Focus MI, and the goal of today's presentation is to highlight lessons learned and also go over a final campaign summary report for the program. As many of you may know, the Patient Navigator Program Focus MI was one of the key quality campaigns for the American College of Cardiology nationally. I want to give special thanks to our founding sponsor, AstraZeneca, who helped to provide support for the program since its inception. Lastly, I want to thank the countless individuals from facilities across the United States who helped to make the program a success. The objectives of today's presentation are to explain how participation in the Patient Navigator Program Focus MI shed light on opportunities for improving gaps in care for patients with myocardial infarction, and to also distinguish how participation in the Patient Navigator Program Focus MI helped to lead change and the ability to overcome many of these challenges. So let's provide a little bit of history about the Focus MI program. So why did the ACC take on the Patient Navigator Focus MI campaign? As is probably well known to many of you, after a patient is hospitalized with a myocardial infarction, there's a heightened risk of readmission, in particular within the first 30 days. National efforts have been focused on trying to reduce the risk of readmission for patients with myocardial infarction and other cardiovascular conditions. Four out of five hospitals are penalized for these readmissions after a hospitalization for a myocardial infarction, and to this day approximately one in four patients continue to be readmitted within 30 days after an initial hospitalization for a myocardial infarction. There are multiple drivers of hospital readmission, many of which are present in patients hospitalized with a myocardial infarction. These include stresses within the hospital, increased fragility on discharge, a lack of understanding of discharge instructions, and the inability to carry out discharge instructions, to name a few. The Patient Navigator Focus MI campaign had a number of goals. This included reducing 30-day and 90-day readmission rates for patients hospitalized initially with a myocardial infarction, developing a compendium of best practices to close gaps in care, and facilitating improvement in transition from the inpatient to the outpatient setting for those hospitalized with a myocardial infarction. This is a fairly busy slide, but reflects a timeline from inception to completion of the Patient Navigator Program Focus MI quality campaign. As you can see to the far left, hospitals were selected and metrics were established in the second half of 2017. The program formally kicked off in the first quarter of 2018, extending for eight consecutive quarters with a measurement period ending in the fourth quarter of 2019. A total of 15 hospitals, referred to as diplomat hospitals, participated in the program for a period of two years. Each of these sites had established administrator and physician champions, as well as navigator team members. The American College of Cardiology provided on-site training, toolkits for assessment, webinars, and quality improvement consultation. As part of the program, hospitals received quarterly benchmark reports in order to understand their performance. The diplomat hospitals were expected to collect and upload their data quarterly. The data was shared back with them in a dashboard display to allow temporal tracking of performance and opportunities for quality improvement. They were encouraged to participate in research and publication opportunities related to the quality campaign, and importantly, they were strongly encouraged to share their hospital best practices and success stories with a larger number of hospitals also participating in the Patient Navigator Focus MI quality campaign. One of the big wins for the campaign was the development of a compendium of best practices. For those of you that care for patients with a myocardial infarction, you know that there are a number of key quality measures for this population. Listed on the right-hand side are a select number of these measures and respective tools that the diplomat hospitals used to close gaps in care. There were a number of key takeaways from the campaign, but with a goal of trying to reduce 30 and 90 day readmission rates for those hospitalized with a myocardial infarction, this slide highlights a number of the key lessons learned. First, early patient follow-up is vital. Second, implementing a patient navigator or equivalent position is key. Third, engage your pharmacist as pharmacy involvement helps to reduce the risk of medication errors. Fourth, build bridges with your community partners as most hospitals can't do this alone. Fifth, interdisciplinary teams are essential. And lastly, it is of key importance to get administrative, physician, and clinical team buy-in. So for a good portion of the remaining presentation, we're going to be reviewing data from the campaign. Of note, the baseline time frame for the campaign was a rolling four-quarter period from October 1st of 2016 through the end of September of 2017. Let's dig in. This slide nicely highlights a number of the key quality measures tracked by the individual diplomat hospitals over time. The three columns to the right represent the three time periods of performance, including baseline from October of 2016 through September of 2017, year one of participation in the program, which is calendar year 2018, and year two of participation in the program, which is calendar year 2019. All of the percentages displayed represent median performance for the diplomat hospitals in aggregate. The first measure is 30-day unadjusted readmission rate, which was 10.1% at baseline, falling to just under 10% in year one of participation, and just under 9.7% in year two of participation. The subsequent four measures, along with all of the other measures on this slide, are measures tracked outside of normal participation in the chest pain MI registry and include medication reconciliation on admission, medication reconciliation on discharge, clinician discussion and provision of documentation for specific education on a patient's treatment plan, and clinician discussion and provision of documentation for all prescribed medications, changes in medications, and instruction on how and when to take medications overall. As you can see for these latter four measures, these are largely topped out measures with relatively flat performance over time. The bottom measures represent additional measures that are tracked outside of normal participation in the chest pain MI registry, and of note, include a different baseline time period. This includes the 90-day unadjusted readmission rate, which was 14.1% at baseline, just under 13.5% in year one of participation, and 12.2% in year two of participation. The 30-day unadjusted mortality rate was 2% at baseline. It fell to 1.9% in year one of participation and up to 2.6% in year two of participation. This slide follows the same layout as the prior slide, but includes a number of key quality measures regularly tracked as part of participation in the chest pain MI registry. The first two measures are performance composites for patients with STEMI and non-STEMI, respectively. These are largely topped out measures with relatively flat performance over time. The next measure of overall defect-free care was largely flat through year one of participation in the program, with a notable decrease in year two. Importantly, there was a change in the data definition of defect-free care in the registry in 2019. Prescription of an aldosterone inhibitor at discharge for those with a left ventricular ejection fraction less than 40% saw a notable increase over time from a baseline performance of 26% up to 39% by the end of year 2019. In-hospital risk-adjusted bleeding rates were available for baseline in year one, but were not available in year two. Referral to a phase 2 cardiac rehabilitation program was largely flat over time. Importantly, this is a key quality measure that was identified by many of the diplomat hospitals as an area of focus. The final four measures relate to antiplatelet therapy for patients admitted with a myocardial infarction. The first being prescription of aspirin at discharge was 100% across the board for all three time intervals. The next measure was use of a P2Y12 inhibitor at discharge for those undergoing percutaneous revascularization in a cath lab, and as can be seen, was largely a topped out measure at baseline and in year one, leading it to be a retired metric in year two. Lastly, P2Y12 inhibitor prescription amongst those undergoing surgical revascularization saw a notable increase over time from baseline performance of 46% up to 59% by the end of 2019. And lastly, prescription of a P2Y12 inhibitor amongst those medically managed for their myocardial infarction was largely flat through the first year of performance in the program, with a small increase at the end of year two. This slide is similar in format to the prior slide in that it includes key quality measures tracked as part of regular participation in the chest pantomime registry. The performance data on this slide, however, is divided into three broad groups. The first group represent the diplomat hospitals. These are the 15 previously defined facilities across the United States, and the performance data displayed here is the same as that on the prior slide. The next group are the non-diplomat hospitals. These were 67 facilities across the United States participating in the chest pantomime registry that were asked to abstract and submit a small amount of additional data outside of the registry and also engage and participate in webinars and community calls. It was hoped and anticipated that the diplomat hospitals would be able to share best practices with the non-diplomat hospitals in order to close gaps in care. Lastly, were a group of 1,033 non-focus MI hospitals. These were facilities across the United States actively participating in the chest pantomime registry who did not collect additional data and did not participate in webinars or community calls. As you can see, performance is quite similar for many of these measures across all three groups. Of note, however, were more impressive increases in performance with regard to prescription of an aldosterone inhibitor at discharge for those with a left ventricular ejection fraction less than 40% and prescription of a p2y12 inhibitor amongst those surgically revascularized for their coronary disease after myocardial infarction among the diplomat hospitals. The prior slides largely reviewed data related to the acute hospitalization for patients with a myocardial infarction. As part of participation, the patient navigator program focus MI, each of the diplomat hospitals were expected to collect follow-up data at 30 days and 90 days after discharge. Over the next several slides, we'll be reviewing those trends for the diplomat hospitals. One of the challenges of collecting follow-up data outside of a clinical trial is being able to reach patients in follow-up. Shown on this slide are the percent of patients reached in follow-up at 30 days after discharge for an acute myocardial infarction. Along the x-axis are unique facility identifier numbers for each of the 15 diplomat hospitals. Shown in different shades of orange are quarter-by-quarter performance over time. In the upper right corner are the absolute numbers of patients reached in follow-up by quarter and the median percent of individuals reached within each quarter. As you can see on this slide, there is notable variability within a given facility among the number of patients reached at 30 days for follow-up and notable variability between facilities in terms of the number of patients reached in follow-up. This slide is quite similar to the prior slide except it includes the percent of patients discharged from the hospital after a myocardial infarction reached for follow-up at 90 days. As you can see, there is still notable variability quarter over quarter in the percent of patients reached within a given facility and across facilities. Of note, a smaller percentage of patients were reached for follow-up at 90 days compared to 30 days. As part of the 30-day follow-up, each of the 15 diplomat hospitals did an assessment of a select number of medications including a p2y12 inhibitor. Shown on this slide for each of the listed quarters were the percent of individuals continued on a p2y12 inhibitor, the percent of individuals switched to a different p2y12 inhibitor, and for those that were switched, which drug they were switched to. As is shown on this slide, a majority of patients were continued on their p2y12 inhibitor at 30 days. Among those switched to an alternate p2y12 inhibitor, most were switched to clopidogrel. Among patients no longer taking a p2y12 inhibitor at 30 days of follow-up, a bleeding event or alternatively hypersensitivity or a non-bleeding related intolerance was uncommonly the cause. Similar findings were observed at 90 days of follow-up. Shown on this slide for each of the listed quarters are the percentages of individuals continued on a p2y12 inhibitor, changed to a different p2y12 inhibitor, and for those that were changed to a different p2y12 inhibitor, which drug they were switched to. Consistent with the findings observed at 30 days, a majority of patients remained on their p2y12 inhibitor. For those that switched to an alternative drug, a majority switched to clopidogrel. Similar to what was observed at 30 days, small numbers of patients were no longer on their p2y12 inhibitor at 90 days. Among patients that were no longer on their p2y12 inhibitor, most had not stopped it for a bleeding event or hypersensitivity or non-bleeding related intolerance. This slide shows one of the key learning measures for the Patient Navigator Program Focus MI Quality Campaign. Shown here are the percent of patients by quarter by facility attending at least one phase 2 cardiac rehabilitation session at 30 days of follow-up after discharge from the hospital for an acute myocardial infarction. As you can see in the right upper corner, the median performance ranges between 22 and 29%. Similar to the last slide, this slide highlights the percent of patients attending 12 or more phase 2 cardiac rehabilitation sessions at 9 days of follow-up after discharge for acute myocardial infarction. In the right upper corner, you can see that the median performance ranges between 20 and 34%. Thus far I've shared a lot of data. I did however want to take the opportunity to share what our diplomat hospitals are saying. On the left-hand side, under overall program satisfaction, there are three particularly poignant quotes. The campaign was great. I would like us to continue reaching out to the patient post 30-day discharge. We'll continue to review readmissions weekly, continue to work as a team approach, and the role of the nurse navigator with the experience and expertise to listen, understand, and translate the needs and information from the patient proactively into communication, connection, and action for the patient is the major pivot that facilitates the patient moving forward on their recovery journey to health rather than moving backwards or being at risk for readmission. And on the right-hand side, a number of bullets related to practice changes, including takeaways related to alignment with national focus on social determinants of health, earlier engagement with patients to show that they had support, and continued navigation post-discharge, better tracking and training of information for the PDSA process with a more detailed focus to key opportunities for improvement, and continued review of all AMI readmissions, now on a bimonthly basis. Use of standardized discharge instructions, which incorporate cardiac rehabilitation information, medication information, and acute myocardial infarction information. Having cardiology fellows enter the cardiac rehabilitation referral orders, and having the cardiology fellows attend the AMI readmissions review. Following a debrief with each of the 15 diplomat hospitals, key additional practice changes were identified. These include having a follow-up appointment with cardiology within seven days, continuing 30 and 90-day follow-up calls as a matter of routine, utilizing dedicated medication reconciliation with a pharmacist on discharge, leveraging mobile health referrals for a remote cardiac rehab gym on a hospital unit, embedding risk calculators within the electronic medical record, reviewing all readmissions to determine the etiology of the readmission, improving patient education, care coordination, and transition, all with a goal of reducing care variability, increasing interdepartmental teamwork, utilizing a cardiology nurse navigator to see all acute myocardial infarction patients, and striving to achieve real-time data abstraction, while at the same time working more closely with different support teams. Overall, the Patient Navigator Program Focus MI Quality Campaign had a number of key takeaways. Throughout the campaign, participants were extremely satisfied with the program. The top campaign measurement of success for participants was a decline in the AMI readmission rate, and 41% of programs believed that a readmission rate reduction occurred at the conclusion of the program. Care coordinators were the most involved staff members, compared to physician leaders and members of the administrative team. Sharing of best practices and strategies to reduce readmissions via webinars, community calls, the listserv, and toolkits were the most helpful during the campaign. The most common challenge for participating facilities was the lack of staffing resources, difficulty in getting data out of information systems, and competing priorities with other QI programs. Early follow-up at 72 hours and 7 days, and later follow-up at 30 days and 90 days, continued to enhance best practices and overall patient care. Pharmacy presence impacts medication reconciliation and accuracy, and is of key importance. A dedicated patient navigator makes patients feel they are cared for and builds trust. Communication between all care team members improves a patient's understanding of their medications and the plan post-discharge. And finally, senior administration support is of key importance. Thank you for your participation today, and on behalf of all individuals involved in the Patient Navigator Program Focus MI Quality Campaign, stay safe. you you

Patient Navigator Program Focus MI

readmission rates

care transitions

early patient follow-up

patient navigators

medication errors