Latest / Becker’s Healthcare Podcast / Peter George, MD, MBA, FACC, FASE, FASNC, Chief Medical Officer of Cardiovascular Services at UnityPoint Health

Transcript

Peter George, MD, MBA, FACC, FASE, FASNC, Chief Medical Officer of Cardiovascular Services at UnityPoint Health · Becker’s Healthcare Podcast

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  - Welcome to the Becker's HealthCare Cardiology and Heart
• 1:02
  - Surgery podcast. I'm Mariah Taylor, assistant editor, and
• 1:05
  - I'm thrilled to be speaking with Peter George,
• 1:07
  - chief medical officer of cardiovascular
• 1:09
  - services at UnityPoint Health. Thank you so much
• 1:12
  - for joining me today, doctor George. I'm really
• 1:15
  - excited to learn more about all the work
• 1:16
  - you're doing in heart failure care. But before
• 1:19
  - we dive into my questions, I'd love for
• 1:21
  - you to introduce yourself and tell us a
• 1:22
  - little bit about your background.
• 1:24
  - Sure. Thanks, Mariah. Thank you very much for
• 1:26
  - having me. I was born and raised in
• 1:29
  - Ohio. I actually spent most of my time
• 1:31
  - there for my medical training, did a little
• 1:33
  - bit in Michigan, and then, spent most of
• 1:35
  - my time in cardiology practice in Ohio, and
• 1:37
  - just recently came out to Iowa and joined,
• 1:40
  - UnityPoint Health as their chief medical officer for
• 1:42
  - cardiovascular services.
• 1:43
  - I've been here about three months and really
• 1:46
  - enjoying,
• 1:47
  - my work here with, all the folks in
• 1:49
  - the in the Des Moines area.
• 1:50
  - But I've been traveling around Iowa to all
• 1:52
  - of our different markets into Western Illinois and
• 1:54
  - and, hopefully, up to Southern Wisconsin soon as
• 1:56
  - well.
• 1:58
  - Excellent.
• 1:59
  - Now cardiology is going through some very interesting
• 2:02
  - changes recently,
• 2:03
  - often because of federal changes in policy, changes
• 2:06
  - in the demand and the need from patients.
• 2:09
  - And I'd love to know a little bit
• 2:12
  - about what you what cardiovascular
• 2:15
  - disease you think has the greatest need for
• 2:17
  - a redesign in health care and why?
• 2:20
  - Yeah. I think that's a great question. I
• 2:21
  - think a lot of people would say heart
• 2:23
  - failure currently, and we would as well.
• 2:25
  - It is really a massive and growing burden.
• 2:28
  - There's probably about seven million adults in The
• 2:30
  - United States who are diagnosed with heart failure.
• 2:33
  - It's a contributing cause in about forty five
• 2:35
  - percent of cardiovascular deaths, and the five year
• 2:37
  - survival around a heart failure diagnosis is about
• 2:40
  - fifty percent, which is comparable to many cancers.
• 2:43
  - So it's a big deal for patients clinically.
• 2:45
  - It's a big deal for patients financially, and
• 2:47
  - it's a big deal to our,
• 2:49
  - health care system financially as well. It's a
• 2:51
  - dominant driver of costs and hospitalizations.
• 2:54
  - It accounts for a huge, share of our
• 2:56
  - health care spending.
• 2:58
  - It's, you know, upwards of 70 plus percent
• 3:00
  - of costs with high thirty day readmission rates,
• 3:03
  - for our hospitals and our health care organizations.
• 3:06
  - And, again, it is the leading cause of
• 3:08
  - hospitalization in older adults, and it's, really a
• 3:11
  - top source of something that's potentially avoidable in
• 3:13
  - terms of admission. So we all, have a
• 3:16
  - great deal of focus on it right now.
• 3:18
  - There's really a lot of complex and fragmented
• 3:20
  - care needs that go along with heart failure
• 3:22
  - in terms of treatment.
• 3:24
  - There's ongoing,
• 3:25
  - optimization of medical therapy. There's monitoring patients for
• 3:28
  - decompensation.
• 3:29
  - There's lifestyle management. There are often devices and
• 3:32
  - advanced therapies,
• 3:34
  - that are applied, you know, for treatment
• 3:36
  - for patients. And, implement implementation gaps are really
• 3:40
  - kind of wide in heart failure. The outcomes
• 3:42
  - can vary greatly, and the care is often
• 3:44
  - reactive rather than proactive.
• 3:46
  - So it makes it a very challenging
• 3:50
  - disease
• 3:51
  - or disorder to treat.
• 3:53
  - Redesign is probably more urgently needed for
• 3:57
  - various reasons. Currently, there's a fee for service
• 3:59
  - model that incentivizes
• 4:01
  - more volume over value. And as we move
• 4:03
  - to value based care models,
• 4:05
  - we're going to need to incorporate things like
• 4:07
  - remote patient monitoring, digital and home based tools,
• 4:10
  - upstream prevention,
• 4:12
  - integrated care pathways, etcetera, etcetera. So,
• 4:15
  - pharmacology
• 4:16
  - has really advanced in this area, and so
• 4:18
  - we really
• 4:19
  - focus highly on that. But it really is
• 4:21
  - about,
• 4:22
  - how care is delivered in terms of a
• 4:24
  - system redesign and what we need to be
• 4:25
  - doing rather than just the technology and devices
• 4:28
  - that are available, because they're great and they're
• 4:30
  - growing exponentially. But I think how we deliver
• 4:32
  - the care,
• 4:33
  - hasn't kept up, you know, as fast as
• 4:36
  - some of the things that we can utilize
• 4:37
  - to deliver the care.
• 4:39
  - Excellent. And what is UnityPoint Health doing to
• 4:42
  - redesign heart failure disease management? And how are
• 4:45
  - you getting clinical and administrative leaders aligned on
• 4:48
  - a new model?
• 4:49
  - Yeah. It's a great question, I think, in
• 4:50
  - the in the kind of the crux of
• 4:52
  - it. So what we're doing here at UniPoint
• 4:54
  - Health is really trying to build on some
• 4:56
  - of the,
• 4:57
  - care
• 4:58
  - care work that was, you know, in a
• 5:00
  - transformation phase the last several years. So in
• 5:02
  - around 2022,
• 5:03
  - there was a heart failure transformation project that
• 5:06
  - started here,
• 5:07
  - and they really incorporated things like HealthSnap, which
• 5:09
  - is, an app or,
• 5:11
  - in a in a company that deals in
• 5:13
  - remote patient monitoring
• 5:15
  - and chronic care management. There are a drive
• 5:17
  - AI driven, excuse me, care management protocols that
• 5:20
  - can be utilized,
• 5:21
  - things like patient education resources,
• 5:23
  - support groups.
• 5:25
  - And then the organization made a real commitment
• 5:27
  - to grow both cardiovascular and oncology
• 5:30
  - through service lines. And I think that commitment
• 5:32
  - to the service line leadership structure that brought
• 5:35
  - me here, that brought my partner, Charisse Van
• 5:36
  - Sloten, into a new position as VP of
• 5:39
  - operations,
• 5:40
  - and then we work together, has really, I
• 5:42
  - think, exemplified the work that the organization and
• 5:44
  - the commitment the organization has made to really,
• 5:47
  - not only look at heart failure disease management,
• 5:50
  - but all of cardiovascular care. So some of
• 5:52
  - the core elements of the redesign for the
• 5:53
  - heart failure management program model are standardized
• 5:57
  - system wide protocols,
• 5:58
  - again, around stronger guideline directed medical therapy optimization.
• 6:03
  - That's really around, and I won't get into
• 6:05
  - it as much here, but a lot of
• 6:06
  - the folks that listen to this podcast will
• 6:07
  - recognize the four pillars of you know, medications
• 6:10
  - that, go into
• 6:12
  - a lot of the work around GDMP,
• 6:14
  - the guideline directed medical therapy.
• 6:16
  - We've done prior work, and we want to
• 6:17
  - build on that prior work here. So things
• 6:19
  - like, lowering in hospital mortality,
• 6:22
  - we look at things called an O to
• 6:23
  - E ratio, which is the observed mortality
• 6:26
  - versus the expected mortality,
• 6:28
  - you know, based on patient risk factors. We've
• 6:30
  - been able to reduce that in a significant
• 6:33
  - way with our prior work, and we continue
• 6:34
  - to work on that here at UnityPoint Health.
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  - In terms of, you
• 6:38
  - know, having our mortalities,
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  - which is, you know,
• 6:41
  - an unfortunate part of any of the care
• 6:43
  - we give. But, heart failure, again, is a
• 6:45
  - very complex and challenging
• 6:47
  - disorder, and so it affects a lot of
• 6:48
  - people of all ages. But in the older
• 6:50
  - population especially,
• 6:52
  - there is in hospital mortality, and we wanna
• 6:53
  - reduce that as much as we can. So
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  - everything we can do on the inpatient side,
• 6:57
  - but also on the outpatient side of medicine,
• 6:59
  - we're trying to do. There are tiered pathways
• 7:02
  - by heart failure type because there are different
• 7:04
  - types of heart failure. There's heart failure with
• 7:06
  - what we call reduced ejection fraction. That's what
• 7:08
  - a lot of people think of when they
• 7:09
  - think of heart failure, kind of a big,
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  - boggy, saggy,
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  - not functioning well heart.
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  - That's one type of heart failure. There's also
• 7:17
  - heart failure with preserved ejection fraction. So people
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  - have pumps that work just fine and pump
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  - blood and oxygen
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  - just fine, but they're stiff hearts and they
• 7:25
  - don't relax well. And so that can fit
• 7:27
  - in the category of heart failure with preserved
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  - ejection fraction. You can have acute heart failure
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  - episodes. You can have chronic heart failure management.
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  - All of these things that we're trying to
• 7:35
  - focus on here at UnityPoint Health and that
• 7:37
  - health care organizations around the country are trying
• 7:40
  - to focus on, I think becoming more proactive
• 7:42
  - in our work, again, with remote patient monitoring
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  - with rural access for patients through things like
• 7:48
  - platforms that utilize virtual health care, and telecardiology.
• 7:53
  - Those things really can go a long way
• 7:55
  - in being able to treat patients where they
• 7:57
  - are without having to having to
• 7:59
  - excuse me, utilize transportation for patients and bring
• 8:03
  - them to us. We can go to them
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  - and do home care. We could do virtual
• 8:06
  - care.
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  - So those things really help a great deal.
• 8:09
  - Some of the things we'd like to incorporate
• 8:11
  - here that we're still talking about are things
• 8:13
  - like dedicated heart failure coordinators and navigators and
• 8:15
  - integrated teams that we already have of cardiologists,
• 8:18
  - primary care doctors, pharmacists, nurses, dieticians, etcetera, that
• 8:22
  - really can deliver this care to patients in
• 8:24
  - a holistic and integrated way. So patient empowerment,
• 8:28
  - things like addressing social determinants we're doing with
• 8:31
  - rural access
• 8:34
  - and transportation, as we talked about, measurement, analytics,
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  - value based alignment,
• 8:37
  - real time dashboards so we can track all
• 8:39
  - of our medication adherence, our readmissions
• 8:42
  - so we can target
• 8:43
  - less,
• 8:45
  - readmissions,
• 8:46
  - lower length of stays for patients so they
• 8:48
  - don't have to be in a hospital as
• 8:50
  - long? And then, again, how can we connect
• 8:52
  - that to outpatient services like home care, telehealth,
• 8:55
  - clinic, where we can keep people out of
• 8:57
  - the hospital and deliver care without having to
• 8:59
  - bring them in. So, you could go on
• 9:01
  - and on here, but those are probably some
• 9:03
  - of the things I would recommend or, you
• 9:05
  - know, just recount that we're doing here at
• 9:07
  - Unique Point Health and continue to try to
• 9:08
  - do for this redesign.
• 9:10
  - That's incredible. I mean, that's a lot of
• 9:12
  - moving parts that you're managing and trying to
• 9:14
  - redo.
• 9:15
  - What aspect of this redesign has been the
• 9:18
  - most difficult, and how have you overcome it?
• 9:21
  - Yeah. I think, again, a great question. So
• 9:23
  - I think the most difficult thing when we
• 9:25
  - try to align services in anything, including heart
• 9:27
  - failure, is around people and culture, because that's
• 9:30
  - always the most you know, change is hard.
• 9:32
  - It's not that change is bad. Change is
• 9:34
  - a lot of times good. It's just hard.
• 9:36
  - So when we try to work to change
• 9:37
  - clinician and staff behaviors,
• 9:40
  - overcoming some therapeutic inertia, we might encounter
• 9:43
  - cross market collaboration in a big system like
• 9:45
  - ours. If we're going to have a system
• 9:47
  - structure around heart failure, how do we do
• 9:49
  - that in all of our markets
• 9:50
  - and still have a centralized theme
• 9:52
  - and get people on board with
• 9:55
  - the tactics and the strategy we're trying to
• 9:57
  - adopt? So adoption of new workflows across this
• 10:01
  - kind of large, multi market integrated system
• 10:04
  - can be very challenging.
• 10:05
  - Why it's the hardest is, again, some of
• 10:07
  - the things we, I think, mentioned that that's
• 10:09
  - the therapeutic inertia. There's some resistance, sometimes a
• 10:12
  - workflow change. Providers can default sometimes to what's
• 10:15
  - familiar to them. We all do. I'm included
• 10:17
  - in that.
• 10:18
  - This has been traditionally an episodic care practice.
• 10:21
  - Right? So people come in with these exacerbations
• 10:24
  - of heart failure. We treat them. We diurese
• 10:26
  - them. We get fluid off. You know, we
• 10:28
  - talk to them. We try to educate as
• 10:30
  - much as we can, and then we send
• 10:31
  - them out of the hospital. What we're really
• 10:33
  - starting to focus on is the fact that
• 10:35
  - there's chronic nature of heart failure. It really
• 10:38
  - is a longitudinal care model. It it with
• 10:40
  - punctuations
• 10:42
  - of, you know, these acute episodes or or
• 10:44
  - inter intervening
• 10:46
  - episodes that occur,
• 10:47
  - it's no different really than, you know, heart
• 10:49
  - attacks, if if you're talking about coronary artery
• 10:52
  - disease, where you try to prevent folks from
• 10:54
  - having problems.
• 10:55
  - But during that longitudinal prevention, it is punctuated
• 10:58
  - by these acute episodes that you have to
• 10:59
  - treat. But we wanna be proactive to keep
• 11:01
  - them out of the hospital, and that can
• 11:04
  - lead to fragmentation of care, especially in a
• 11:06
  - large system. Again, aligning primary care doctors with
• 11:08
  - cardiologists,
• 11:09
  - with hospitalists,
• 11:10
  - with pharmacists,
• 11:12
  - post acute teams,
• 11:14
  - shifting our focus from a siloed to a
• 11:17
  - team based mindset. And, again, that's always difficult,
• 11:20
  - for some people to get their head around.
• 11:22
  - But once you can make that change and
• 11:24
  - have it reinforced,
• 11:25
  - then I think it becomes reflexive for folks
• 11:27
  - and, and it starts to really, bear fruit
• 11:30
  - and give you great results. So how we
• 11:32
  - overcome that is really strong, visible leadership. Again,
• 11:35
  - the commitment the organization has made to starting
• 11:38
  - an organized service line for cardiovascular care,
• 11:41
  - targeting engagement and champions, getting peer champions on
• 11:44
  - board, especially in each of the markets to
• 11:46
  - really help,
• 11:47
  - you know, foster and further the work. We
• 11:50
  - can have incentives through specific heart failure metrics,
• 11:53
  - performance reviews tied to compensation, quality metrics, etcetera.
• 11:57
  - You can phase the implementation. So you can
• 11:59
  - start in high volume markets like Des Moines,
• 12:01
  - for example, and then get quick wins and
• 12:04
  - and good patient success stories and begin to
• 12:06
  - leverage that and scale it across your system.
• 12:09
  - And that's probably the best way to approach
• 12:10
  - it. But then getting the families and the
• 12:13
  - patients themselves involved,
• 12:14
  - as centers for redesign for the care, letting
• 12:16
  - them know how this can lead to reduced
• 12:18
  - hospitalizations,
• 12:19
  - better quality of life,
• 12:21
  - involving them in the design, the action plans,
• 12:23
  - you know, connecting them with support groups and
• 12:25
  - resources that they need to stay out of
• 12:26
  - the hospital.
• 12:28
  - Excellent.
• 12:29
  - And as you said earlier, a lot of
• 12:31
  - hospitals are trying to find new ways to
• 12:32
  - care for heart failure patients and improve those
• 12:35
  - outcomes. From your experience with the redesign,
• 12:38
  - what is one thing that hospitals could start
• 12:40
  - doing this week that would improve their heart
• 12:42
  - failure care model?
• 12:44
  - Yeah. So one thing that's high impact that
• 12:46
  - hospitals can do pretty quickly is to implement
• 12:48
  - kind of a standardized
• 12:50
  - discharge protocol bundle. Again, then looking at every
• 12:52
  - heart failure patient, that would include things like
• 12:55
  - medicine reconciliation. So, again, going back to guideline
• 12:57
  - directed medical therapy,
• 13:00
  - patient and family education,
• 13:01
  - and doing so called teach back sessions where,
• 13:04
  - you know, you can explain and educate families,
• 13:06
  - caregivers, and patients, and then have them kind
• 13:08
  - of, you know, give that back to you,
• 13:10
  - teach back to you what they learned from
• 13:12
  - you, and to make sure that they're they
• 13:13
  - have a good understanding of what they're looking
• 13:15
  - for in terms of, you know, symptoms that
• 13:17
  - can look like decompensation,
• 13:19
  - things like daily weights, heart rate heart rate
• 13:21
  - and blood pressure measurements, low salt low salt
• 13:24
  - diets. You know, just making sure people understand
• 13:26
  - the education. And if they can tell tell
• 13:28
  - that back to you, it's it's pretty good
• 13:30
  - indication that they, you know, they absorb what
• 13:32
  - you were saying to them. Scheduling follow-up appointment
• 13:34
  - visits in person before they leave the hospital,
• 13:37
  - and so you can get, you know, between
• 13:39
  - four to seven days after discharge and get
• 13:41
  - them back into the clinic in person or
• 13:43
  - virtually or phone follow-up phone follow ups or
• 13:46
  - check ins within twenty four to seventy two
• 13:47
  - hours after they leave. You can do all
• 13:49
  - these things. There's strong evidence that they work
• 13:52
  - to, lower readmission rates for patients,
• 13:55
  - and they address key gaps. You know, again,
• 13:57
  - incomplete discharge planning or poor patient understanding of
• 13:59
  - what the plan of care is, they address
• 14:01
  - those things, and they're quick to launch. You
• 14:03
  - really don't need any new major technology or
• 14:06
  - hires. You can use existing staff of nurses,
• 14:08
  - case managers, pharmacists, schedulers, etcetera, and then incorporate
• 14:12
  - the the physicians into this, and you can
• 14:14
  - do this pretty quickly. So you can define
• 14:16
  - this bundle in a a day or two,
• 14:17
  - you know, create a checklist,
• 14:19
  - in the EMR or on paper,
• 14:22
  - you know, give people their roles, assign their
• 14:24
  - roles, and, whether they're educating the patient, following
• 14:27
  - up with the patient,
• 14:28
  - you know, what they're gonna do in the
• 14:30
  - process. You can do a quick pilot. You
• 14:32
  - can track the results of that pilot, and
• 14:33
  - then you can scale those results to the
• 14:35
  - rest of the system.
• 14:36
  - You can leverage existing resources, again, that already
• 14:39
  - like at UnityPoint Health, we can,
• 14:41
  - have tools for integration and a watch so
• 14:44
  - called watch, w a t c h,
• 14:47
  - acronym framework. And that's really wearables,
• 14:50
  - things we can do for remote patient monitoring
• 14:52
  - and institute action plans. We have home care
• 14:54
  - support for these folks. So those are things
• 14:56
  - that a lot of people have access to
• 14:58
  - already in different organizations that they could leverage
• 15:01
  - immediately. But, again, the the care bundle is
• 15:03
  - something people can do mostly with their existing,
• 15:06
  - framework and the existing personnel they have.
• 15:08
  - Perfect. Well, thank you so much for joining
• 15:10
  - us today and sharing everything about your new
• 15:13
  - heart failure care redesign. This has been such
• 15:16
  - a great discussion, and it's been a pleasure
• 15:17
  - having you. Moriah, thanks so much for having
• 15:20
  - me. I really enjoyed it. Thank you.