Service Operation Management

Group 9
Banavathu Kranthi Kumar M077-18
Sagar Raj Singh M109-18
The Duke Heart Failure Program
• Founded in 1925
• Duke Medical school was a leading research
institution and, along with Duke University
• Awarded $37M by NHLBI to run a 3,000-patient
randomized trail studying the effects of a tailored
exercise program on hospitalization and mortality
rated of heat failure patients
• Ralph Snyderman exclaimed “ we are loosing
money hand over fist on the heart failure disease
management program”
Congestive Heart Failure
THE DISEASE
• CHF was a chronic and progressive condition in which a diseased heart ceased to pump blood efficiently

• • In addition to the physical exam and medical history, the doctor would measure the ejection fraction, which
was a measure of the percentage of bold the heart’s left ventricle pumped with each contraction

THE PATIENT POPULATION

• From 1979 to 2000 CHF deaths increased 148% and by 2000, the overall death rate for CHF was
18.7%
• Conditions includes hypertension, diabetes mellitus, peripheral vascular disease, previous heart
attack, obesity and kidney failure

CHF Disease burden

• The annual direct cost for treating CHF patients was $22.2 billion+ $2.1 billion in productivity loss
• Readmission were 2% for two days. 20% within one month, and 50% within six months.

Treatments
Life style: patients were asked to alter their diet and limit their salt intake
Medication: vasodilators, diuretics, digoxin and Warfarin & aspirin
Surgery and medical procedures: surgery could be used to treat a coexisting condition that contributed to
heart failure.
• These included valve replacement, LVAD, angioplasty, CABG and defibrillator implant
Management of Heart Failure
FELLOWSHIP
Duke created a fellowship program
contemplating on how to manage
high-cost and loss-making disease.

PROCEDURE
Discharge patients early from
hospital, identify patients in need
of more therapy and intensive
follow-up and get patients
appropriate medication
INHOUSE DEVELOPMENT
Snyderman opted to develop
disease management service
inhouse to increase access to
health care, educate patients and
to apply evidence based medicine
in systematic manner.
INITIAL FUNDING
Duke committed $125000 in seed
money to the program which
would cover salaries of nurse
practitioner, secretary as well as
data analysis
Management of Heart Failure
Staffing and Resources Phone Calls

01 Clinic had staff of 10 Duke

cardiologists who spent one 4hour
block in a clinic per week. The
clinic had 3 NP’s and pharmacist
04 NP’s scheduled calls within one to
two weeks after visit. The NP’s also
contacted patients within three to
five days of hospital discharge.
who were always available by
phone.

Patient Entry to the Program Patient Education

02 Patient was referred to the

program while in hospital for CHF
or the patient would be referred by
PCP’s.
05 Two forms: Counseling and
dissemination of printed material
about heart failure.

Frequency of visits PCP-CHF relationship

03 The clinics wanted to make sure

the patient arrived back in 3
weeks. Once the CHF stabilized the
frequency of visits grew from 2-3
06 Communication between PCP-CHF
was the major issue. Clinic’s
electronic record was not shared
with the PCP.
months
 Disease Management
• Approach to manage chronic conditions that aimed to prevent problem
before it occurred
1

• Emphasized coordination of care , communication with patient, physician

and self manage
2
• Common in disease as diabetes , heart failure, asthma and end stage
renal disease
• Differed from routine care in frequency ,intensity and utilization of
3 system to ensure delivery
 Disease Management
Models

Provider- Located within

For Profit – Marketed physician organization and
services to three groups integrated health system
Administered by clinic staffed by Payer – Develop own DM
Private managed care
pharmacists ,nurse practitioners, programs instead purchasing
companies (85%)
educators and social workers Common disease – Diabetes ,
Public managed care
Backbone – Teaching self Asthama and end stage renal
contractors(10%)
management tools and Health program identified by
Employers(5%) monitored patients physician , pharmacy utilization
Competitors- American Low penetration data and claim/encounter data
Heathways, Matna
Healthcare and Landcorp Present in 31% of 1040 physician
organizations surveyed in
registry
 DUHS Outreach
Expansion to Alamance County
 Natural step and 30 year relationship with doctors and hospital in Alamance
 Hospitals occupancy rate was 70% greater than Duke
 Funds for expansion and assistance in structuring the clinic
 Communication lapsed between Duke and Burlington when director departed
 CHF program ended in mid 2000 suffering loss of leadership and drop in occupancy
rate
Promising Practices Program
Begun in 2000 , sponsored home health-care visits to underserved low income
Target disease- Diabetes, Asthama and hypertension low penetrative strategy
Successful for sensitivity to predominately African American
Participants received medical evaluation and education and coaching in lifestyle
change
 Program Outcomes
• Reports highlighted improved clinical outcomes , decreased costs,
impatient and emergency department utilization
• Patients received the best available care first
• Decrease in hospital admission rates
Inferences
Admission rates- 1.86 to 1.21 ,length of stay - 7.67 to 6.07 days
Clinical visit – 7.8 to 12.9 , outpatient cost 27% , inpatient 38%
Patients reported improved quality of life
Going Forward
CHF clinic funding issue
Someone responsible for the well being of the entire system, he found it
difficult to see “doing the right thing” lose money
Thank You