Supporting Providers to Support Patients: Northwestern Hospital’s Story

‘A big part is empowering the patients,’ says Chicago cardiologist of Medicare pilot program that allowed for increased follow-up and improved health outcomes

After returning from a trip to Haiti in 2015, a patient came to Northwestern Medicine, a hospital system in Chicago, with a buildup of fluid in his body, a sign his heart was failing. 

The cardiology team reduced the fluid and immediately prescribed a “whole slew of medications” before sending him back home, recalled Dr. R. Kannan Mutharasan, Medical Director of the Bluhm Cardiovascular Institute South Region.  

This is not an uncommon story. 

But all too often the patient coming home from the hospital needs much more help managing complex medication and self-care instructions than they receive.

According to Mutharasan, patients with congestive heart failure often leave the hospital with eight to 10 new medications to take daily – all of which are crucial to managing their condition. But many patients struggle to understand their care, and without follow-up from medical staff, they often land back in the hospital. 

To support the patient’s success, a pharmacist on Northwestern’s staff took the time to help him arrange all of his pills so he knew when and how to take them and better understood his treatment. 

Northwestern offered this benefit as part of their participation in Medicare’s Bundled Payments for Care Improvement Model. As part of the model, hospitals and physician group practices are required to share the specific planned interventions and changes to their current health care delivery system that they intend to establish for patients. At Northwestern a nurse practitioner and pharmacist work with patients to better manage patient care following a hospitalization for a serious health episode.

“Medicine really matters in the first 30 days” after someone is hospitalized, Dr. Mutharasan said.

Heart failure patients often suffer from other chronic conditions, and will experience complications such as sepsis or kidney failure, he said. Maintaining direct contact with the patient during the transitional care period is very helpful.” 

While the pharmacist would explain the treatment plan, the nurse navigator would call patients to make sure they could get to their appointments, which also made a difference.

Mutharasan recalls that Northwestern took part in the model because they were interested in gaining real world experience in value-based care, and how to think about value-based care for cardiovascular patients, and patients in general.

“A big part is empowering the patients. If [patients]do a couple simple things, they can really impact the course of care,” he said.