Chelsea Christensen, PA with Sentara Cardiology Specialists, describes a patient monitoring protocol using radiofrequency technology to detect CHF symptoms to prevent hospital readmissions.
I'm Chelsea, um, and this is HFAs. Um, so just a quick disclosure and agenda to go over before we move on is I do have to disclose that I'm a speaker for Zole. The agenda of what the talk looks like is we're going through a couple different parts. Part one is looking at some basics of the device at first. Part two is looking at how this has worked at Virginia Beach and what the data at Virginia Beach looks like. And the last part is looking at a couple different hospitals in the area and comparing. So CHF readmissions, a huge topic in terms of health care and costs and other things that we'll get into later in the slides. Um, just generally speaking off to the left there 1 in 5 patients are readmitted within 30 days after their initial heart failure admission. So 20% are coming back in 30 days and about 33%, 1 in 3 are coming back within 90 days. Um, the chart over there on the right is just showing you there's multiple, um, kind of physiologic events leading up to that actual tipping point of the weight starting to increase and the symptoms starting to occur that lead to that, uh, heart failure event. Um, but we're trying to think earlier here for how can we catch that, um, exacerbation before the patient ends up back in the hospital. Cost-wise, the projected cost of hospitalized heart failure patients and remissions is supposed to cross 70 billion by the year 2030, which is not very far away. Uh, CMS is targeting hospitals with financial penalties if they fail to achieve a 30 day remission rate that's in line with national averages. What we do right now for heart failure patient education is we really talk with patients about their sodium restriction, their fluid restriction, tell them to watch their daily weights, make sure they take their medications. A lot of that relies on us having the staff and the time to sit and talk with patients because there's a lot of education that goes with heart failure. And if you don't have a dedicated staff member or, like I said, just the time to spend with patients and go over it with them, there's a good chance we're missing. Saying those patients we're not educating them properly and they're going to be coming right back. Interestingly enough, even when we do have the time to spend with patients and go over diet and weights and all these things, that half of patients that come back for CHF free admission have gained an insignificant amount of weight. So even if we do teach the right things, sometimes it doesn't always flag the right way and teach that patient when they should be coming back, and they're still going to end up coming back. Um, so enter HFAMS or heart failure Management System. HFAMS is the acronym there. This is a picture of the device. I explained to patients that it's a white sensor in the center of a sticky patch goes over on the left side, kind of in that left axillary region that the graphic is showing you there. The pictures at the bottom show you what comes in the box when it gets shipped to the patient's house, so they get a bunch of new patches in there because they should change the patch about once every 7 days to keep that clean. The sensor is in there. The sensor itself sits on the charger part once every couple days. It needs charged. The gateway device is that smartphone looking thing, and the gateway device is how the sensor pings the data over the gateway device over Wi Fi to a Zole patient management network or a separate Zole website. So that is what comes to the patient when it arrives and what the device looks like. How it works is that it measures TFI or thoracic fluid index, which is an early indicator of heart failure decompensation. TFI itself is a unitless numbers that measures a deviation from the patient's established baseline in terms of their pulmonary fluid. Atriums utilizes radar waves to capture and establish a baseline TFI. So everyone, once they put that device on, is zeroed at about a 1.00, and you're trying to keep those little blue dots right within those tiny red dashes if you can see that on the picture on the bottom. Um, once the device is placed on the patient, it takes 3 consecutive readings, so over 3 days, where it takes 1 reading every day to then zero it as that patient's baseline. Important thing to note there is that the patient should be mostly dry from a heart failure standpoint, because if you put the device on and it zeros that baseline and the patient maybe hasn't been adequately diarrheed or they're about to go into the hospital because they're not feeling good, it's going to skew all of your future readings. So they should be mostly dry when they put the device on and zero it as their baseline. An increase in TFI outside the normal range for 3 readings in a row is going to trigger an alert to the managing provider. So remember we're measuring pulmonary tissue hydration, put it on a mostly dry patient, zero that baseline, but if they start to retain fluid, it's going to thicken up that pulmonary tissue, change the radar wave that pings through the chest cavity, and then change the reading that is recorded as TFI and sent back to that ordering provider. Where all that data goes is to an independent diagnostic testing facility or IDTF that Zole operates and manages. Um, the IDTF is there 24/7 monitoring the patient's data, and they're the ones that kind of send that alert out then once it triggers in their system. Um, depending on how you set this up as an ordering provider, it can be set up to get alerts as a phone call to you, or it can be set up as an email. When I first started this project, we had a set up that Zo was calling me almost every morning at like 8:12 on the dot. I would get a phone call from Zole. I would never answer it because I'm running around rounding, but they leave me a voicemail and say, you know, these are your three patients you need to check on today. So it was for me a good reminder to make sure I was getting in. And checking it, um, but eventually we transitioned and did it to just email. And so I do like that a little more, I think, where I have a little bit more of kind of a hard copy in my email every morning, reminds me to pull up this old website, um, and check those alerts, um, before I start running. An example of a TFI alert here is there is a bit of an art to this that I'll explain a little bit more, but you can see that technically in the beginning of this, those little blue dots, they're not a perfect 1.00, but they're hovering pretty close to that baseline area where you want them to be. So even though those are outside some of those tiny red dashes, I'd probably get an alert, you know, maybe here or here for those ones that are slightly above, but I would log in, check and say, you know what, there. Mostly flat. They're pretty close because you also don't want to risk overtreating a patient, calling them, over diariesing them, putting them into an AKI or giving them hypotension, and still ending them back right back in the hospital. So watching patients closely to kind of having that clinical judgment of when is the right time to reach out and call the patient. So you can see in the thicker red dashes when that person really pops up outside their baseline, and that would be for me the trigger where I'm calling that patient to check on them. Um, atriums can monitor other things other than volume management or TFI, so it does have the ability to do heart rate, respiration rates, sleep angle, and activity. Um, off to the right is a picture of a weekly report. So in addition to just getting these TFI volume alerts on patients, each patient will get a weekly report. The weekly report is useful if maybe I'm seeing someone in the office and they want to know what their readings have been, or I get a message from the office that says so and so called and they want to know how things look here. If I haven't reached out to them, I always caution and try to Educate those around me that if I haven't called them everything's fine, but if they have questions about what that data looks like, then I can always pull that weekly report and say, oh, they've been nice and normal. That's why I haven't gotten any alerts. So but I do say that I'm mostly just looking at the TFI, that top box there, that volume management is the main thing I'm using here when it comes to HAs. To also point out that Atriums has some ECG monitor monitoring capability, so it can detect VTEC greater than 150 for over 30 seconds, Afib greater than 150 for over 60 seconds, and pauses greater than 8 seconds. Um, it's neat that it has this added ability, but it's in no way a substitute. Or Zyo or an actual event monitor. So there have been cases where maybe you have a patient who comes in a new Afib and they're in heart failure at the same time and we diurese them, we shock them, we get everybody back on track, and I have sent some patients home with an HAs on their left side and a yo monitor over on them for arrhythmia management. Um, I have disclosed to patients when I realized that's what's happening. The first time it happened, I kind of backed off a little bit and was like, Well, you actually are going to wear a ZO2, so maybe that's a little too much. But at that point I had already introduced the H fibs, and the patient was like, No, no, no, I need to wear your thing too because I'm not coming back here. And so even though they might Have two patches on for a little bit overlapping there. Usually people are wearing an event monitor for maybe 2 weeks and so it's kind of that double patch life for a week or two before they're done with the event monitor and then they're sticking with the HAMs for up to 90 days. So even though it has this monitoring capability, of course it's not a substitute for an actual event monitor. Exclusion criteria. So who cannot wear an HAs? Like I touched on earlier, anyone who's acutely volume overloaded, you wouldn't want to put it on just because it's going to skew those baseline readings. Otherwise your two main criteria are anyone who's about to start dialysis in the next 90 days or anyone who's currently implanted with a device that is capable of monitoring their fluid. So certain CRTDs, cardioms, and LVAD, um, I'm frequently looking at pace. Reports just to see if there's any mentions of Optaval or Corbie to tell me for sure if there's monitoring of that volume. Otherwise, the takeaway here is that that's almost everyone. That's a huge amount of patients as long as they don't fit into those two exclusion criteria. It can be any EF, any age, any type of heart failure, their first admission, their 15th admission. It doesn't matter. So it's a huge amount of heart failure patients that qualify for this. OK, so let's switch to what this looks like at Virginia Beach or what it has looked like rather. Um, I started ordering these in April 2024 over at Virginia Beach. Currently I'm up to nearly 300 HAs that I've ordered total since then. Um, now remember, it's a revolving door. Everyone wears the monitor for up to 90 days. So it's not like I'm actively monitoring 300 patients. That's just the amount of devices I've ordered since we started, um, but people are constantly putting on and returning to keep monitoring that data. Uh, patient identification, remember those two exclusions to remind you about if they're starting dialysis in the next 90 days or if they have another device that can monitor their fluid. There's no harm in them if you were to put an HAs on them if they had another device. Just obviously insurance doesn't want to cover it if they've already covered some other device that's supposed to be doing that for them. These are patients that I would see at Virginia Beach General while I'm rounding, as well as stable outpatients because it can be ordered from the outpatient setting. You do run a little bit of a risk there that you're not, I guess, guaranteed that you know that patient is truly evolemic, maybe the way you have when you've been monitoring that patient in the hospital for a couple of days and you feel comfortable knowing that they're evolemic when you're about to send them out the door. Outpatients a little bit more of a different game. Um, but these are frequently patients that I would see that are talking to me about, you know, here's my weights, but I still find that on, you know, Monday, Wednesday, Friday, I have to double my Lasix, even if I try not doubling it. I still need this and I'm scared I'm going to be back in the hospital, and they're trying to go through all this stuff with me and asking what can they be doing and what are they missing. So HVMs has been a good way to almost give them a little bit more peace of mind that we're getting more data and we're monitoring that patient every day to follow them a little bit more closely. My clinic day falls on a Friday and so even if I do see some patients where they have a little bit of edema and I'm worried they're starting to retain fluid again, what I normally do is maybe I double their diuretic through the weekend and say by the time the device shows up at your front door on Monday, Tuesday, then you're back on your regular diuretic dose and then you put the device on. So sometimes I do a little bit of like a preventative diuresis before they put the device on to zero that baseline. Um, again, sometimes these are people that were have been in the hospital multiple, multiple times. Sometimes they're people that was their first time, uh, their first rodeo with heart failure in the hospital, half pep, half ref. Patient motivation is key in choosing these patients, but I do think it's not been as much of a driver lately as we've kind of more so just opened the floodgates in terms of who can get these devices at Virginia Beach General. So at first when I was started, it was that patient that when we're running by on rounds and they're frustrated asking what can I do differently? I did everything right. I'm still in the hospital. To me that was the perfect patient for HAs because they're actively seeking out how they can change to stay out. Of the hospital, but lately it's just been anyone that's IV diary staying in the hospital that we're seeing and following while we're there, and they may not be asking how to stay out of there, but most patients that are in the hospital with heart failure are pretty tired of it, and it really doesn't take me much saying, you know, I can send you home with a sticky patch. It's going to monitor your fluid. Uh, it'll send me a reading every day, and if your reading starts to go up, I'll call you. And that's basically the sentence I say. And the patient says, yes, I'll do that. You know, I think I had one patient tell me no. Otherwise, everyone else has always said yes. But nearly all patients for this project were identified by myself, some by my fellow APP team members at Virginia Beach General as this started to pick up steam. They could tell me if they were direing someone or if they thought someone was a good candidate. They came across. The hospital's team at Virginia Beach General has been very good to helping me identify patients that way. I've made it very clear to them that if They want an HMMs on a patient. It doesn't necessarily mean they need a cardiology consult for that patient. So I was very clear with my team about that, but they can secure chat me. I also have told them, you know, they have enough things to keep track of and monitor that there's just someone, there's diary saying I asked them to secure chat me that patient so that I can quickly through their insurance, their renal function, and just make sure that they meet the criteria to have HAMs ordered. And of course our heart failure navigator nurse team over at Beach, Cindy Furman, has done a great job helping to identify those patients for me too. Profiles over the place, ages ages 44 all the way up to 98, being the most elderly patient I've put it on. Family support, I think, is key. A lot of times someone may have scoffed at putting a device like this on a 98 year old, um, but a lot of, a lot of them are pretty with it and as well as have really good family support. So even patients that maybe are demented that you think wouldn't be great, if they'll keep that device on and they have a family member, a lot of times it's a family member who's Sitting there saying I'm so sick of this person being in the hospital. I have to keep calling off work. My job's going to fire me because so and so is in the hospital again and I have to sit there with them. So a lot of times it's talking with the family that becomes the primary person that's like, yes, we will do this. We have to do anything to keep this person home. And of course varying renal function, EF range all over the place, normal kidneys all the way up through CKD4, as long as it's a stable CKD4 and not approaching dialysis. The workflow, um, insurance wise, so who's currently not compatible with insurance is Medicaid, Tricare, and Self-pay, obviously. Um, most of our patients at Virginia Beach General are Medicare Part A and B, which will always cover. Um, once I've identified this patient on rounds later when I'm writing notes, I'm kind of going through the chart and making sure insurance is compatible. I do caution people that as we've gotten more APPs set up to order and they're nervous about remembering the right insurances will cover, that when you order the device, Zole will run it through the insurance, obviously and Insurance doesn't approve it, they won't send the device to the patient. So if there's any question that you're worried whether or not the insurance is going to cover and you're worried that patient's going to get stuck with a huge bill because their insurance didn't cover it, that won't be the case. If their insurance doesn't cover it, they will not get the device. So when in doubt, I always tell people just order and try, and if they get denied, they get denied. Um, the order is put in via a separate Zole patient management network. So the website I was talking about where I get on and look at alerts, that's also the website I'm getting into, put in this clinical e-order. Once that order is placed, I would notify our local Zole rep, Rachel Champion. Um, she would get an alert that the order came through and within a couple of minutes, she would let me know that the patient got approved or not. So it's also very quick that they have this process in place to know if the insurance approved it. Um, when I order it, I always put a little blurb in the chart, um, just a quick progress note that says something about, you know, the patient wants to pursue an HAs to help monitor their fluid and keep them out of the hospital. Um, I always say this does not need to delay discharge because in the beginning we saw some hospitals seeing the word Zole and thinking, oh, they have to stay here and wait till their life vest is fitted, and that's not the same product. They don't have to stay in the hospital and wait for it. It is going to show up at their house. Um, in terms of education, Rachel um with Zole does a great job coming. To provide more education in person with the patient. So again, I can't reiterate enough that I really have not spent much more time with the patient having to explain this. So it's a couple more minutes. If I don't mention it when we're in the room rounding quickly, I come back later and say, you know, hey, the little line I said earlier where I can send you home with a sticky patch to monitor your fluid. Patient says yes, and I say, Great, someone's going to bring you a folder or a handout, go over more details with it with you, and I'm out. So I'm not spending. Time they're having to educate and do things. Rachel and Zo provides great education on their end. And as it's grown at Virginia Beach, our cardiac floor nurses have been educated with how to educate the patients. It's in their discharge instructions when patients go home. And so it also triggers the nurse to say, Hey, don't forget so and so ordered an HAs for you. It will be at your house. Make sure you put it on, all that kind of stuff. So they're getting a lot of reminders throughout their hospitalization to make sure they put the device on when they go home. And same with spas, as spa, cardiac floor nurses are doing a great job with that. Once I order and everything is kind of flowing here, like I said, then I'm adding these patients to my own individual epic list, and that's a good way that I've kept all those patients in one place to be able to track this data and um follow up on these patients, know who got readmitted, all that kind of stuff. This is what the order looks like in this old patient management network, um, to give you an idea of when I log in and I click there's a little tab that says e-ordering or something like that. Um, my information always defaults at the top, so I've gotten this down kind of pat where I pull up the patient's demographics on one screen and on my other screen I have this order set up, um. So I can throw in their name, their date of birth, their address, their phone number. Then I've switched to their face sheet that I have kind of wrenched into my favorites, and I'm just putting in their insurance carrier and their policy ID. So just those two pieces of information, you don't have to freak out about putting in their secondary and their group number and all that stuff, just those two asterisks of what their primary insurance is and that policy number. Um, the monitor information and settings below that is all defaulted, so you skip over that. Top right recent medical history, you have to click yes that they were recently in a heart failure exacerbation. So again, that doesn't say that they were admitted in the hospital. It just said they required, you know, recent adjustments to their diuretics, and they have issues with volume management. So you're attesting yes, putting in the date, it can just be today's date when you order it. The two exclusions are there, so are they currently Scheduled to start dialysis in the next 90 days, you're clicking no. Do they currently have a device that can monitor their fluid? You're clicking no, clicking what type of heart failure there for indications. You do not have to upload any supporting documentation, so don't panic. That's not an extra step. You go right past it and then you're just clicking submit e-order. So I know that looks a little daunting, but I can throw in one of these orders in less than a minute. Once you're used to doing it and you kind of know where to grab the information, it goes very quickly. Um, once ordered, the HAMs is then shipped to the patient's house. Time from discharge varies for activating the actual HAM's device. Remember, it's important that the patient puts it on pretty quickly when they get home from the hospital. Sometimes patients put it on within a day or two, sometimes they're waiting up to a week. Sometimes they wait a little longer. We'll talk about those patients, um, but once they receive. The device, it comes in this big green and blue box shows up by FedEx again, usually within a day or two. They open the box and it has a big phone number on it that says Please call this number to activate. So the patient calls and Zole is on the phone to go over how to activate the device, how to put it on, how to take care of it. So again, Zole handles all that education with the patient. It's not something we have to do on our end. Um, if the patient has not called to activate the device with, I want to say it's within 3 days, then Zole starts calling the patient every day to say, hey, we know you have this device. Do you want to activate it now? So again, great follow up on the Zole side that we don't have to, um, fit into our workflow at all for them to try to get that patient to activate. Zo also has customer service for the device 24/7. So, um, if I'm ever getting sort of technical questions or patients that have a, you know, they're worried they're not transmitting as long as I can see readings and assure them that it looks OK. Otherwise I tell them they can call customer service or anything else. So, um, again, I'm not spending too much time having to troubleshoot these things with patients if they can't get it to charge or something like that. Um, they wear the device for up to 90 days. And you have the ability to order another HTM's device after that. So it's just approved in 90 day chunks. It is possible to keep wearing them, and some patients have done that. Um, you want to have to start to have a conversation of HTMs being kind of a short-term volume management plan. And the way I explain to people is if I have to call you one time and that whole 90 days you're wearing it, then we should talk about a cardio menses as a long term volume management plan here. But there are some people that maybe are don't want to go undergo an implant or, you know, just think, well, I just need another 90 days to get it together. I won't have any trouble. So sometimes they do another monitor as a result. So what do the alerts look like in terms of the volume that I get to me? Um, they're all over the place. Sometimes there's plenty of patients that have zero alerts the whole time they wear it, and I never have to call them and I never get an email about them. Sometimes there's people all the way up to 30s, 40s, 60 alerts while they're wearing the device. Um, to point out here that the number of alerts doesn't always correlate to how many times I had to call that patient. So it's not like I got 60 alerts on someone and I had to call them 60 times. That's ridiculous. Um, this is just, again, if you remember in the beginning I was showing you where there's some that kind of plateau around a baseline where I'm getting an alert for that. But I'm reviewing it and saying no, I don't need to call Mr. So and so today. So it's checking that alert but not necessarily calling that patient. So even that one that had 63 alerts, I called him 4 times in the course of his 90 days, and that still was a lot just so you know, that's not normal for me to call someone that many times. The one, the 39 alerts, the 8 contacts, that was actually my sweet 98 year old, and I learned to call his daughter and actually every time I would call she'd be like, Dad, did you take your Lasix today? Chelsea's on the phone. And so you kind of get to know these people, and he of course would have skipped his Lasix and the HMMs would have caught it so we could get him back on track and keep him out of the hospital. If I do call the patients, of course it's a telephone counter in Epic, so I'm always documenting. When I talk to that patient, what we talked about and if I make any changes to their medication is in Epic. At the end of the 90 days, patients return it back um to Zole. Some patients don't complete the full 90 days, maybe they wear it a week or two, a month, 6 weeks. They can mail it back whenever they want to. It's up to them. Uh, skin irritations was a little bit more of an issue in the very beginning. And so once we kind of educated patients a little bit better, they take that patch off. It's a strong adhesive that's on there. And so if they have an irritation, I tell them they take it off, let their skin kind of air out for a day or two, wash it with soap and water. A lot of people weren't doing that, but then they can put the patch back on. It cannot go in a different place. I get that question. A lot has to stay in that one same spot. So if they have a true, you know, blistering nasty skin reaction, obviously they're done with it. Um, if they want to try, they can put a clean patch back on and see if it's kind of cooled off, but it's ultimately up to them if they think it's too itchy or it's bothersome, they don't want to do it. I tell them it's up to them if they want to throw it back in the back in the box and mail it back, that's completely fine. That's their choice, um. As I mentioned earlier, it's been a good segue for our cardio mems program at Virginia Beach. So Dr. Treja is the main kind of implanter of our cardio mes program over there. Dr. Almar also implants. Myself and my colleague Jen Dreyer are the two APPs that manage our program over at Virginia Beach. And so this has been a good kind of segue of almost like a test run, like a bridge to cardio mes, if you will, of someone that can. Stand the benefit of that daily monitoring and kind of see it working in real time where they understand that I will call, change their medicine, and hopefully, you know, prevent that future readmission. And so these are patients that I'm calling, talking with them on the phone. They're nearing the end of their 90 days and they're saying, Chelsea, what am I going to do when this is up, you know, or this thing's really annoying, it's been awesome, but I don't want to wear another one. And I say, Well, we need to talk about a cardio mems then. And so cardio. It is a great idea on paper, but a lot of times just, I think the nature of heart failure when you're trying to explain to a patient that they need this implant to monitor their fluid. I think most patients think, Well, I'm not going to need that, you know, I'm going to go home, take my medicine. I'm going to do everything right. I'm not going to be that person that needs that monitoring. We know what kind of the track record is going here in terms of their heart failure, but I think it's important that once they have that HAM. It's been kind of a good test run to show them that who's going to be compliant, answer the phone, take their medicines when we call to segue into cardio mes as their longer term volume management. So we've had 7 patients total that have gone from HAs to cardIMs so far, and we actually have another 6 that are either waiting for insurance authorization or maybe are already scheduled and we just haven't implanted yet, but a good number of HMM's people have moved on to cardioio mems. Just some quick highlights. Distance and medical care is key here. So we have a lot of patients, you know, that live in North Carolina, a lot up on the eastern shore that feel like, you know, they will get in the car swollen, huffing and puffing, and drive 2 hours to come to Virginia Beach because they want to be at the hospital where their physician practices. And so this has been almost like a security blanket sometimes these patients that live far away that know that they're being monitored and that someone has eyes on them. Um, like I mentioned to patients that are maybe holding that second dose of Lasix or they're going to be going out to dinner, or they're going on vacation, so they're kind of self-titrating their medications not to ruin their time, but then ultimately ending up in the hospital maybe a week after that decision. Cheat meals, people will treat themselves a little bit, which is fine. I always caution people they need to live their life. That's why they're wearing the HAs so that if they do something like that, I can hopefully catch it and we can readjust instead of them having to be penalized for eating something they normally don't eat. Um, some patients wear it a couple of weeks, uh, or don't activate it and return it. Um, just for an example, there's one patient who wore 3 weeks. It was like, I'm feeling good. I'm sending this back. They come back at 4 weeks, um, in a heart failure exacerbation, same as someone where 4 weeks they return it. That person was readmitted in 6 weeks. So even if they kind of get on a good trajectory here where they're like, I'm feeling good, I don't need to do this, the data shows that there's a good chance they're probably gonna still come back to the hospital. Um working with Dr. Treja, he obviously does a lot of structural things, so I see a kind of a subset of structural patients. Most of the patients that I encounter in terms of structural are starting that pre-taver workup. So they're patients that he's bringing in for an outpatient right and left calf, sometimes a BAV. If he balloons them, we'll admit that patient and based on their right heart cath values, a lot of times if they seem to be slightly volume overloaded, I'll hit him with a dose of IV Lasix before I discharge them the next day. And order an HAs for when they go home. That way that patient can wear the HAs either leading up to their taver or sometimes we've had a few patients where the timing has been just right where they've managed to wear it the whole 90 days pre and post taver, and we've had good success at keeping those patients out of the hospital. Um, I see sometimes patients that have been discharged after taver and maybe they've been hypotensive or they had a mild AKI and so their diuretics were placed on hold when they went home, um. The thought is, you know, when you come back to the office or when you see whoever you're seeing next, we'll then discuss if it's OK to resume that stuff. But a lot of times those patients come back in heart failure a week or two later. And so while it's the right call to hold their diuretic at discharge, this gives you an extra set of eyes to say, OK, well that was the right decision then, but now we're 3 weeks later and I'm not seeing this patient until 6 weeks down the road and they're already starting to retain fluids. So we can catch these people sooner and prevent that readmission. Um, and so interestingly, of this subset of structural patients that are Dr. Talreja's structural patients, none of them got readmitted in 30 days. So as long as they were wearing their device and were in contact with them, that's a 0% readmission rate for his structural patients at Virginia Beach. Um, let's go through a couple patient examples, um, of, so you can see kind of what I think when I get these alerts and how I manage this. So, um, there's just a few here, but again, you're trying to keep those blue dots within those tiny red dashes. Um, you can see this patient kind of hovers up a little bit even on 4/14, he pops up a little bit, um, but interestingly, the FDA recommendation for the device is if you get an alert and you're. Trying to decide whether or not you're going to call a patient, wait one more day. And so if you're in doubt and you don't want to, you know, call and overreact to something, just give them one more day and see what their reading looks the next day. So for him, you can see he popped right back down there and I didn't have to call it. But then later on 4:22, he jumps up really high, so I call, say what's going on? and he's like, Well, I'm feeling good, so I'm not taking my Lasix in the evenings. I'm only taking the morning dose. And so he gets back on his BID dosing. And you can see the dot come right back down, which is another neat thing about this is that it's almost like instant gratification that you know the patient did what you told them to do because you see their reading start to come back down. Um, this patient a little bit all over the place, but kind of generally following the same plateau there. Um, around 3:18, I kind of got tired of him hovering up here enough because I was like, well, he was down here, here, he's not, he's floating up a little bit more. And so I called him, left him a voicemail. I said, you know, make sure you're taking your Lasix. If you are taking it appropriately, I need you to double it for a couple of days. This is the same patient. A few days later, you can see, I think I called him on the 18th. He comes down a little bit, but then he tracks up again on the 24th, 25th. So I call him again and I say, what's going on? You got my voicemail, so we talked and he's like, Yeah, I got your voicemail, and it made me look over my discharge list of my medications from the hospital, and I realized I'm not taking my medications right and I was actually doubling my muscle relaxer instead of my Lasix. um and so we joked and I said, Well, you probably feel very relaxed, but also short of breath, and he said yes. um, but so I thought this was just. A neat example of, you know, patients aren't always having the proper education or the proper understanding or the mis miscommunication about their medications. And so if he hadn't been prompted to really look at his medicines and be like, Whoa, whoa, I'm taking these wrong, he was probably going to end up back in the hospital. So we went over his meds, make sure he had them all straight, get him back on actually doubling his Lasix, and you could see at the end there on the 26th he comes right back down because he's actually taking things the way he's supposed to. This is one of my um outpatients that I ordered for, and she was interesting because she was at home getting IV antibiotics for a mitral valve endocarditis. She's a retired nurse, very highly educated lady, but we realized that every time I was calling her was coinciding with when she was getting her IV antibiotics for her endocarditis treatment, so. Think of the saline, the amount of fluid that comes in those antibiotics or saline flushes that go with it as well. And so because of tracking her HAM's readings, we were able to kind of have her do like a prophylactic Lasix dose when she was going to get the IV antibiotics to help keep a lady like this who has no business being back in the hospital dealing with a big infection, so helping keep her out of the hospital as a result. Um, this lady was an afibber patient. She was waiting her Afib um ablation. Um, she was covering up a little bit and then started to come up around on the 12th. She had her ablation a few days before that. I called her and she said, Well, I started holding my Lasix like a week before my procedure because I was nervous that I was going to have an accident while I was in the hospital and I was going to be really embarrassed. And so we get her back on her twice a day Lasix dosing and she floats right back down to baseline. Um, this is another Virginia Beach kind of hospital employee who we know really well who does a super good job of watching her diet, watching her weights. She does a phenomenal job at taking care of herself, but at the very end of her 90 days she stays steady the whole time and at the very end she starts to climb up a little bit. So I call her and say, What's going on? She's like, Well, I went to the circus over the weekend and had a hot dog and popcorn with my family, and she never eats that kind of stuff. So HMM's caught it. She comes up a little bit, double her torsemide, and she starts to come right back down. This is the last patient example. Um, this patient, he comes up pretty soon where you can see he activates. I think he's discharged right on the 30th there, the end of May, activates a couple days later. He's at a nice baseline and then right away starts to climb up. So I call him like, Are you feeling OK? And he's like, Yeah, I'm doing great. The hospital food was terrible. I'm finally eating Chick fil A, and I'm like, Well, that's great, but your numbers are floating up. And so we had a little chat about that. Have him double his Lasix for 3 days, and he starts to come back down. OK. Um, quick slide just about the dreaded frequent flyer. Um, a lot of times I think all of us, no matter what hospital you work at, you probably have 1, maybe 2, maybe more patients, um, where you're used to seeing them once a month, once every 6 weeks because they're always in the hospital. And maybe they're doing everything right at home, maybe they're not, um, but I think frequent. A lot of times those patients are, it's like, well, you know, let's just copy the note forward. All I have to do is change the date and the NT pro B and P, and it's otherwise the same exact note I wrote six weeks ago, you know, um but these patients, I think a lot of times we feel like we don't have a way to break the cycle because we've tried everything for them, but AtriMs can break this cycle for them. All right, so just an example of patients that are in the hospital like every month, every couple of months, and then once they get the atriums they have no readmission after that, OK. OK, so let's get to some data numbers here. Um, again, on the left, I put those national averages where 20% of patients are coming back in 30 days, 33% of patients are coming back in 90 days. Off to the right, this is the first chunk of data from when I did grand rounds last year, so October 2024, about 6 months' worth of data. My 30 day readmission rate was 5.5%, and my 90 day readmission rate was 14%. Um, on this slide, I always point out that even the patients that did get readmitted, they did not come back in heart failure. They came back with pneumonia, COPD, C. diff, something else that still, um, you know, dings us, um, as a group for having that readmission. Um, there was a patient that, you know, there was a patient that had an AMs on and was like riding a bus and the bus got in an accident and the patient like fell off their seat and hurt their arm and got readmitted and I was like, oh, readmission, even though it's not heart failure, it's a bummer that they're not necessarily tracking it's a heart failure readmission, but I digress. So this is the 1st 6 months of data. The next chunk of data is one year worth of data. So April 2024 to April 2025, my 30 day readmission rate is 8%, my 90 day readmission rate is 12%. And then the most up to-date data is current from April 2024 when we started all the way till now, October 2025, 30 day readmission is holding strong at 7%, and my 90 day readmission rate is 15%. Um, super fancy table here showing those percentages side by side. I like to put them side by side, and you can see there hasn't been that much fluctuation in it, despite these groups of patients more than doubling each time. So the 1st 6 months of data was only about maybe 40 some patients. That first year of data was around 100 patients, and like I mentioned, the most up to-date data is with nearly 300 patients. So even though I'm really increasing the cohort every time, the numbers still look really great, OK. Um, so how about the patients that did come back in heart failure? Remember my 30 day ribain rate is 7%, 90 day 15. If you break down those patients further for who actually did come back, only a handful of them came back in heart failure. So if you calculate that out further to kind of a CHF specific 30 day readmission rate is 1.7%, and a 90 day readmission rate of people that are actually in heart failure 3.2%. So what about those people? What about the people that did come back in heart failure? Did we miss it? Did I forget to call them? What happened? Um, so the chart, the kind of reading on the left is a patient where I touched on this earlier, but I ordered the AMs on the end of October. This is last year. um, he didn't actually activate the device until the 9th of November, so about 2, 2.5 weeks later, um, and then he gets readmitted right here on the 5th. with nice normal reading so I didn't have any alerts on him, but you can probably wager that he had started to retain fluid. He's already more than 2 weeks out from his hospitalization. He's probably starting to feel bad, short of breath, and it's like, oh no, I was supposed to put that device on so that this wouldn't happen. So he puts it on then, and by then he's already retaining fluid. So it kind of skewed baseline readings there of why he ended up back in the hospital. Patient on the right, not much change in her reading. She floats up a little bit, but She mostly stays stable and so I didn't reach out to her and she gets readmitted right here on the April 21st if you can see that little blue dot there. She is in heart failure. She needs diarrhes. The note with her is that she has severe pulmonary hypertension. So um with these patients, I have seen that those patients, that kind of subset of patients are a little trickier to manage. They do tend to come back in in heart failure and kind of fly under the radar in terms. Of the HAs catching it. I will look at echoes and things like that before I order the HAMs. If I see severe pulmonary hypertension, I'm still ordering it for the patient because the risk is so low for the patient to wear a sticky patch on their side to help keep them out of the hospital that it's always worth trying, in my opinion, um, but I use maybe exercise a little bit more caution that maybe that patient still might end up coming back because of um their what they have going on. Um, other two examples of people that ended up back in the hospital with heart failure, um, same kind of thought on the left where this lady has nice stable, um, readings. I never had any alerts on her, but she has severe pulmonary hypertension. She ended up getting readmitted. Patient on the right, I think, is a good story to talk about because remember the way that HMMS works is through radar waves measuring pulmonary tissue hydration. And so this patient really didn't get any shortness of breath. Everybody retains their fluid differently. This patient got significant lower extremity edema, so he was always very frustrated that he was back in the hospital still, even after I'd promised him the holy grail with HAbs that I was going to help keep him out, and we had to have a lot of heart to hearts about that. But if they're truly retaining only in their legs, HAMS is going to miss it because it's only looking at pulmonary tissue hydration, OK. Um, just to give you an idea of how many of these I order, so this is per month since we started, how many I order. So in the very beginning, um, we started kind of slow with picking up and me trying to understanding the alerts and how it was going to impact my workflow, um, but now 2025, I'd say I probably order maybe about 5 a week or so, um, of patients over at Virginia Beach that I'm seeing or from the office standpoint. Um, so we're, I'm in a good rhythm of ordering a lot of them to help keep these people out of the hospital. OK, last chunk hospital data and the impact of HAM's, um, on our hospitals. So this data is all December 2024. OK, so it's Virginia Beach and the top I'm highlighting that 30 day readmission rate. So remember I started in April 2024 and you're not immediately going to see any change in numbers because it's. 90 day device. So you're not necessarily putting an atris on someone expecting next month your readmission rates to be phenomenal, but you're looking at that frequent flyer, that person that hopefully over time you're starting to keep out of the hospital. So you can see those readmission rates start to float down towards the end of the year, September, October, November, December at Virginia Beach General. This is the most up to date, um, current readmission rates at Beach leading up to July 2025, so broken down per month that 30 day readmission rate. Um, some months were looking pretty good. Um, some months are maybe a little bit more of a struggle. I don't want to talk about June. I don't know what happened. Um, I, someone asked me the other day what happened in June and I was like, maybe tourism. Um, just with Virginia Beach, we get a lot of, um, vacationers, so I was like maybe they threw off my numbers. I don't know, but that's what the every month breakdown looks like at Virginia Beach General. Um, this is our current cumulative score. So our actual goal, um, is, I believe, less than less than 18%, um, for our 30 day readmission rate. So Beach is running at a 17.4%, um, which is of the hospitals I'm familiar with and I've pulled numbers for, um, is the current best. Um, this is spa, so we'll talk about Princess Anne a little bit and our initiative there. They're running at 22.1%, but spa is more so just starting to pick up in terms of ordering HAs and the volume that they're getting there. So I'm hoping with the monthly breakdown there I highlighted towards the bottom that you can see in June they looked beautiful at 17.2%. So I'm hopeful that as more HAMs get ordered at Princess Anne, um, that we'll see those similar kind of numbers that we have seen at Beach now. Um, DSMR readmissions, so this is readmissions that were encompassing CHF, sepsis, pneumonia, and COPD, and this was an email I got from um Kim Span, our chief of medical staff over at Virginia Beach General. So she was showing me that the drop in CHF readmissions, this was back into earlier this year, remember it's 18.1% an hour or 17.4%, but she was saying with a goal of less than 18, this is probably driven by the improvement in CHF readmissions, and this is the first time that she could remember that had been that low. Um, so what do we do from here? So we're expanding the program. So as of September 2024, um, it had already expanded to Centerra Princess Anne. My colleague Jacqueline Knox saw what I was doing at Virginia Beach, and she's primarily based at Princess Anne, so she stepped up to the plate and offered to start ordering over there. Since then, we have created, let me backtrack, remember when you order the device, you own that data for now. That's how it works. And so all the orders that I place are in kind of my account and I track those patients. Jacqueline was her own account for Princess Anne. But since then I've dragged Kristen McElhaney and Jen Dreyer, Amanda Beaman, Zana Longvall, and of course Jacqueline into this as well, and they're all part of my beach spa team. And so we've created that account to then kind of be our beach spa pool of HAs. And so anyone if one of them puts in an order, it dumps into that pool account for them all to be able to follow. Um, as I make our schedule APP-wise for my pool, I'm assigning them each a week on our schedule of who's in charge of following those HAs alert by the week. So even if Kristen gets an email alert, if it's not her week, she knows it's Za's week to track it, she's going to delete that email, but Zena will be the one if it's assigned to her on the schedule that actually logs into this old patient network and checks those alerts to see what's going on with the patient. Um, it is active at Lee, so Dr. Cohan is set up to order. He's ordered a few of them. Um, Mike Stuck, Ashley Latoi, April Rawlings has ordered a few, so I'm trying to push and expand and get it out there. Remember, you can order it from the outpatient setting. So discharge clinic, I think, is a great pocket to be using this. Our discharge clinic at Virginia Beach is run by C Sierra Davis. She's set up to order and has ordered a lot of them. Catherine Shepherd is set up over the P. A office and to point out it's not just Sentera that's ordering it. This is a nationwide device and that Dan Kiernan Colleen Quick with Bayview Cal are ordering for their patients. Dr. Michael Jenn's office is ordering. Chesapeake Regional is ordering HFAMs, so it's more and more widespread. It's not just something funny we found here. Um, so this is almost near the end here. This has since become a wave initiative, which has been a lot of new meetings and learning curve for me, but meetings of how do we scale this out to enterprise-wide across Sentera. David Muirir has been a huge supporter for me in all of these meetings and helping to navigate this wave initiative, so I greatly appreciate his assistance with that. Um, there are a lot of ongoing meetings and discussions about how to get this linked into Epic. So how can we get an order for HAs into Epic? Obviously the follow up question is, well, whoever puts in that order, then what are you doing with that data? So we still have to work on that on the backside, but to get that order in, I know would already be a lot easier than having to pull up that separate website and order it every time. Um, I think overall, I would like to highlight the need for additional staff here. This program has gotten really big, OK, and it's substantial, and the data shows the impact it can have on our system. I think with that being said, it probably can't continue to work the way that it does right now. It works with myself managing my patients and with our small APP pools monitoring it, but I think ultimately if we're talking Santeraide, people ordering these all over the place, we do need some sort of infrastructure, and that's how other successful programs across the country do it is some sort of infrastructure of A nurse an MA, an MA, even just a tech, someone that you can train to look at these alerts, kind of set up a protocol or an algorithm where that person can look at this stuff and then approach the designated provider to say, hey, here are the readings. What do you want me to do with their diuretic kind of thing. So I think moving forward it's kind of how do we, how do we grow it from here to contain it because it's gotten so big. Um, and because I was highlighting how substantial everything is here, the Centera ATMs program is one of the top 3 Atriums programs in the nation, so it's really big what we've done here, and it's big in terms of the volume of the devices that I've ordered, but also the data that we've shown here is what makes it a huge successful program. Um, this is just the study in case anybody want to look up the BMA trial, um, of the actual HMMs device being studied that was presented, um, at ACC in 2023 and it was published in, uh, Jack last year, October 2024. And that is it, my friends. What questions are there? Thank you. Thank you. Yes, please. Thank you. What is the cost of this device and in comparison, the cost of a cardio. Oh, that's a good question. It does seem like a good way to go there. Yeah, yeah.
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