Key Insights

• “When we took a step back and looked at our population of cardiology patients, or really our Medicare patients, we saw about half of our new diagnosis of heart failure were happening in the inpatient setting. When if you think about it, we should be able to do a better job of identifying those patients much earlier in their disease.” – Dr. Patrick Goggin
• “We know from multiple recent clinical trials that better optimized guideline medical therapy can help improve quality of life, keep these patients out of the hospital and help them live longer.” – Goggin
• “It’s important for us to lean in and find people that can partner appropriately with us to give the level of care that we want to give through our patients. It’s a disease that you can impact patients’ longevity and the trajectory of their healthcare journey.” – Dr. Jennifer Szurgot
• “What I’ve found when I speak to my patients, they want to know. They want to be involved in prevention of disease. They want to be diagnosed or at least know that there are risks for diseases earlier.” – Szurgot

Key Insights

• “The heart failure program, anyone with that diagnosis, we tried to look at it, but really ended up being more reactive once they’d been admitted. So really it was that program, and we did have a pharmacist that worked with that program, but the volume also was so large that we actually had all of those patients re-reviewed by the team at Stellus and found that about 35 to 40% really weren’t on maximal GDMT.” – Szurgot
• “That intentionality with back and forth with the pharmacist with Stellus has been very helpful and educational. We learn from every one of those interactions and we can apply that to the next patient that we see.” – Szurgot
• “We really took a step back and really approached this as a paradigm shift. We wanted our primary care doctors to own the continuum of heart failure management. What we were noticing is even the patients who were seeing cardiology weren’t optimized on GDMT.” – Goggin
• “There’s still that variability among different physicians and that’s why the partner with Stellus has been so instrumental, because it’s like you’re walking side by side and through the guidelines with the patient and that’s a just a much more effective model.” – Goggin
• “Recently one of the cardiology leads in our network complimented our group for spurring them to pay more attention to this because they see, in retrospect, that it was a gap. And so we’re evolving with them together. We’re not doing this instead of cardiology. We’re doing this with cardiology and Stellus has been instrumental with that.” – Goggin

Key Insights

• “One of the good things that I like with our partnership with Stellus is that we’ve worked out where when they’re sending tasks, the primary care provider is the one that’s driving that and doing prescriptions, but cardiology is always notified of that. And so that’s really helped the collaboration and communication, which is something I think is really important, not just in this, but as a whole in medicine, which kind of gets lost when you’re just getting really busy.” – Szurgot
• “We look at it as more of a partnership. Everybody’s got their perspective and their expertise, and to me it’s another hand to help me and the rest of our team be able to care for patients in the best way possible.” – Szurgot

Key Insights

• “When we started to think about can we do this in-house? And really we knew that we couldn’t and not the way we wanted to. Already having that partnership with Stellus that had been successful, not just in our quality measures, but more in just the communication and engagement from both just let us know that that’s was what was going to continue to happen as we move forward and has been exactly what I would have anticipated and have been very happy with that partnership.” – Szurgot
• “One of the things that we worked on right from the start was having our Stellus pharmacist embedded right in our electronic health record which allowed bidirectional communication between your team, our team and the patient. And then lastly, PCP engagement. Do the physicians, nurse practitioners and PAs, do they understand this clinical pathway? Do they understand what the vision of it is, what the purpose is? How to access it, how to communicate with them. So it takes a lot of PCP engagement.” – Goggin
• “The integration directly into the EMR I think was key because the notes were right there, that communication, the tasking, all of that. I think it also gave Stellus more information about the patient to be able to make a good decision about whether that person would potentially qualify for the program.” – Szurgot

Key Insights

• “I would say my first one was just about cardiology, and was there going to be any negative feedback from that and were they going to be hesitant? So I think that ended up being a good surprise because I wasn’t sure what to expect. I think the other challenge has been how do you get the patients enrolled in the program.” – Szurgot
• “And now going forward, what we’re doing is actually integrating it into our MIP a little bit more real-time. We’ve come up with some ways to do some more point of care conversations, but then also coming on the back end to make it very easy. Once they’ve had the conversation, the enrollment very easily happens without a lot of the clerical part having to be done by the provider.” – Szurgot
• “Provider engagement is super important. You have show why it’s there and how it’s going to work and then they’re more willing to have the conversation because they believe in the program.” – Szurgot
• “Both our navigator and our Stellus pharmacist are embedded in the EHR, so we’re all communicating. So I think communication is key. It’s not uncommon that we get a high priority message from our pharmacist saying, ‘Hey, I think this patient might have a urinary tract infection based on their symptoms could we get her in and seen and tested?’ Or, ‘Were you aware that he stopped insulin yesterday or, you know, a week ago because of a formulary change or ran out or needs a new prescription?’ And so that’s been super helpful. The value is in frequent touch points.” – Goggin
• “We had one patient enrolled and he’s done great. Like he hasn’t been in the hospital, hasn’t been in the ER, and he had some subtle changes to his meds made. But honestly, prior to enrollment, he’d lost his wife to a sudden unexpected illness and just emotionally, he was just struggling and now just having someone call him every two weeks, like he’s just emotionally so much better. I think they talk about gardening as much as his medicines, but like, that’s what he needed.” – Goggin

Key Insights

• “One was a 70-year-old patient referred by the PCP. He had complex medical history and had had a bypass 10 years ago, had heart failure, preserved ejection fraction. He has sub-optimally controlled blood pressure and diabetes and he was also the primary caregiver for his for his wife. Over the course of his enrollment and working with Stellus and the PCP, they got him from one to three pillars of GDMT. His blood pressure improved, his weight came down 20 pounds. His A1C improved. He said, ‘I feel great now. I’m walking three miles a day. My energy levels are better.’ He’s off of insulin and he just really sung the praises of the program.” – Goggin
• “I got a kind of an urgent task from one of the Stellus pharmacists who basically are closer to the home than I could be. And you know, they have them pull out all their medicine bottles and they’re going through it. And I mean, this poor person was just taking a multitude of things that had been off of their Med list for a long period of time. Some things had been duplicates of the same class of drugs. And so, you know, of course that person felt significantly better.” – Szurgot

Key Insights

• “So before this, a pharmacist is someone who gives my patient the pills I prescribe. This is a completely different model than that. Learning to partner with someone and realizing there were some doctors that were not used to that, maybe not even okay with that, but we’re breaking down those barriers through trust, and through time and then taking it from a focused disease-specific clinical pathway and just broadening it out to like all of our high-risk patients.” – Goggin
• “We’re going to have to bring in areas of partnership who have expertise that we do not and as those who have that trusting relationship. When we trust them, then our patients trust them. I think that really can be more of a broader statement for a lot of different disease states with Stellus.” – Szurgot

Key Insights

• “We’re going to continue to move more towards value, really looking at outcomes and how well did the patients do. And that’s going to require a team-based approach, whether that’s APPs on your care team, whether that’s adding in other programs like heart failure, dementia, COPD, partnering with pharmacists in order to make sure that we’re delivering that level of care and that level of expertise and minimizing the number of times patients end up in the hospital.” – Szurgot
• “Value-based care has to be team-based care. It can’t just be this treadmill where I’m seeing 25 patients today, 10 minutes of each per encounter. Seeing them four or six months later and think things are going to go well, certainly not for our high-risk patients. So it takes a multidisciplinary care team with multiple factors, multiple touch points and it doesn’t always have to be me, you know what I mean? So we just need to not only just support our patients, but support our doctors with a more comprehensive set of resources and pharmacy is definitely a part of that strategy.” – Goggin