Physician Roll Call: Team-Based Care in Heart Failure

Heart failure is often accompanied by comorbidities such as COPD and diabetes, and it raises the patient's risk for many other conditions. As multiple-indication cardiovascular medications begin to become available - like the recent FDA approvals of empagliflozin and liraglutide, diabetes medications that also decrease cardiovascular risk - the need for more than one specialist and/or medical professional becomes more and more apparent. Across most fields of medicine, collaborative, team-based approaches to the treatment of patients have become increasingly popular, and for cardiologists, pharmacists, and nurse practitioners that are in contact with climbing numbers of patients with comorbidities, the approach makes sense.

At the Heart Failure Society of America's 21st annual meeting in Dallas, Texas, several medical professionals sat down with MD Magazine to discuss the team-based approach to treating their patients, as well as the challenges faced by this new need for consistent communication between health care providers.

Rob Mentz, MD: So the challenges of where we're coming from and you know it's also challenged because it's increasingly complicated and as you have providers getting more and more specialized and new medications new devices everything it makes it hard to stay on top of everything.

David Aguilar, MD: So, I think this area, in particular, is right for team-based approach because it's a new area for cardiologists in that some people who are going to require more complicated therapies, like injectables, or maybe they're on insulin. There has to be involvement with other specialists who might be more familiar than cardiologists, like endocrinologists.

Mandeep Mehra, MD: We actually want to administer tests and an adjudicated competency in all team members, not just a physician because traditionally the American Board of Internal Medicine only certifies physicians. But what about clinical pharmacists who have an equal stake in the care of these patients? What about nurses and nurse practitioners who have more than an equal stake in these patients?

Lisa Rathman, MSN: There’s still a long way to go in how we collaborate and to know who needs the highest level of care, and who can be transitioned back to primary care to follow, and to make sure the patient stays on their meds, and who continues to follow that patient. So I think team-based care is really very very important for heart failure because these patients have multiple comorbidities. They tend to have multiple social issues and so I think having the entire team of primary care, specialty care, social work, heart failure clinics, disease management programs - I think you need all of those services to figure out what your individual patient needs.

Rob Mentz, MD: The challenge is that, historically I think, things have been fairly siloed so as the cardiologists thought they're going to take care of the lipid management, the blood pressure in heart failure, or other kind of cardiac diseases, and then in your notes and in your conversation with the patient, you're gonna say, “alright talk to your endocrinologist about your diabetes.” So this idea was that each of the different providers was really looking at just one piece of the puzzle, and I think what we're finding is that increasingly all of these puzzle pieces are so intimately related that to really optimize care, it has to be across really their whole comorbidity burden.

David Aguilar, MD: And then there definitely has to be educational resources that are provided to the patients. So I think that when we talk about the team care approach, that diabetes and heart disease is the perfect, or one of the perfect examples, where we'll have to align resources and strategies to provide the best care. So yes, I think it is always important.

Lisa Rathman, MSN: We complain a lot about EMRs, and you know they are sometimes challenging to use, but the nice thing about it is you now have the ability to see what primary care says, you can see what the specialist says, you can see what the clinic business looks like, you can see what the hospitalization looks like, you can see what the labs are, and so we're all on one platform. So I think that has helped tremendously with team-based care.

Rob Mentz, MD: So you know, as we think about the right approach to team-based care, I think there are certain things, whether it's shared EHR, making sure you're having the actual conversation with the different providers and patients and giving them the information they need. But also, at the very least, making sure you're sharing all of the electronic health record data to really try to get over the challenges of medication mismanagement or polypharmacy, and that really can complicate the course for patients and their families.

Mandeep Mehra, MD: We believe very strongly that for a chronic disease like heart failure one has to in fact take a team approach and that's partly why the HFSA is creating its own competency certification initiative.