Mount Sinai South Nassau Hospital: Delivering Advanced Care Locally to Patients with Heart Failure

By Jenn Webster
Thursday, November 14, 2019

A comprehensive Cardiac Wellness Program and the recent addition of on-site services from a board-certified heart failure specialist make Mount Sinai South Nassau a trusted partner for advanced care for patients with heart failure.

Over five years ago, Mount Sinai South Nassau chose to seek Joint Commission certification in heart failure. The pursuit and achievement of The Joint Commission’s Gold Seal of Approval Certification in Heart Failure started a revolution in the level of care patients receive at the hospital. Goals of reducing readmissions and promoting patient self-management led to the development of the Cardiac Wellness Program, which in the ensuing years has educated and empowered clinicians and patients at other facilities throughout the community.

Building on that foundation, a nascent partnership with Mount Sinai Health System is fostering early relationships between patients and physicians who offer advanced heart failure therapies, meaning patients can access such therapies in the earlier stages of their condition, when treatment is most effective.

Advanced heart failure cardiologist Noah Moss, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Medical Director of Mechanical-Circulatory Support at Mount Sinai, reassures his patient as she leaves the Center for Cardiovascular Health.

Overcoming Obstacles

Initial diagnosis of heart failure often takes place during a hospitalization for an emergent condition. At that point, it can be challenging for patients to master the complex regimen of diet and medication that will enable them to avoid rehospitalization.

Pilar Stevens-Haynes, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Director of Noninvasive Cardiology at Mount Sinai South Nassau, came in at the ground floor of the heart failure program, which began soon after she arrived six years ago.

“We wanted to be Joint Commission-certified in heart failure,” she says, noting that certification entails, among other benchmarks, reduction of readmission rates for patients with heart failure. “Our internal evaluation revealed that we were at about the national average. We were determined to be better.”

Patients who were frequently readmitted after heart failure diagnoses included those of advanced age, those with multiple comorbidities — especially diabetes and kidney disease — and those who struggled with the challenges of medical management of heart failure, including understanding complex, evolving medical routines.

“We asked ourselves what we could do better,” Dr. Stevens-Haynes reiterates.

“Though we are at the beginning of this partnership, the future is very bright. We have already seen a tremendous benefit for patients we’ve interacted with, and I am eager to continue our efforts. Our goal for the heart failure program at Mount Sinai South Nassau is to help as many patients as possible.”
— Noah Moss, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Medical Director of Mechanical-Circulatory Support at Mount Sinai Heart

Dr. Moss evaluates a patient prior to starting her diagnostic study.

In point of fact, that endeavor turned largely on how the hospital could help patients help themselves by improving their understanding of their condition and their ability to self-monitor, taking medications appropriately, and more proactively managing their health and wellness overall.

“Internally, we made significant progress with readmissions, working through the whole hospital to educate staff members — especially the nurses who help patients understand heart failure,” Dr. Stevens-Haynes says. “But we had to address patients themselves. So we created a special task force to educate patients and nursing facilities in the region about heart failure.”

The hospital looked at two patient groups: those returning home after hospitalization and those going to local subacute care facilities. A staff training program was developed for nursing facilities interested in enhancing care for patients with heart failure; for patients who returned home, the hospital developed a robust outpatient service hub.

The Cardiac Wellness Program

For patients transitioning back to their homes, Mount Sinai South Nassau created the Cardiac Wellness Program, designed to provide information, medication monitoring and other services to outpatients with heart failure.

Pilar Stevens-Haynes, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Director of Noninvasive Cardiology at Mount Sinai South Nassau, consults with a patient about his condition.

Staff members include a nurse practitioner, a registered nurse and a cardiologist. Dietary staff and a pharmacy are part of the program as well. The goal is for patients to learn how to manage their health, piece by piece. The process is far more involved than what is possible during typical cardiology or family medicine visits, but Mount Sinai South Nassau has made resources available to support the extended physician visits that make the program effective. Ideally, the first appointment takes place within a week of hospital discharge; patients can also be referred directly by a cardiologist.

“When the patient arrives for the initial intake, we go over everything with them,” Dr. Stevens-Haynes says. “It’s a lot of information to acquire, so we take the time necessary.”

Dr. Stevens-Haynes conducts a stress test on a patient to evaluate his progress.

The team first works to ensure patients understand the purpose and correct use of each of their medications. Appropriate dietary changes come next, with a diabetes educator partnering with the cardiology experts to provide optimal, individualized dietary guidance for each patient. Patients learn about their eating patterns and other habits that influence the disease process as well.

They also interface with numerous monitoring systems to ensure they can communicate health information in ways that best fit their needs. For high-risk patients, telemonitoring of implantable devices allows physicians to check health status remotely. The devices flag patients experiencing warning signs, such as increased pressure in their lungs.

Dr. Moss and Matthew Lurin, MD, Assistant Director of Emergency Medicine, collaborate on a patient who has presented in the Emergency Department.

“Because I am able to monitor the numbers,” Dr. Stevens-Haynes says, “I can see when patients are doing well and when they are running into trouble.”

In addition to longer appointments, multiple convenient points of contact between patients and providers are a key component of how the Cardiac Wellness Program helps patients stay healthy and avoid the emergency room. When patients find themselves short of breath or struggling with edema, for example, conditions can deteriorate quickly. Having a service ready to help patients promptly can get them back on track. Patients can visit a provider in the Cardiac Wellness Program when they need to ask a question, get a quick assessment, receive an IV diuretic or see whether they need an adjustment to their medications. Additionally, physicians can perform a check-in to see whether patients are doing well enough to get through an upcoming weekend; a quick visit or conversation on Thursday or Friday can help avoid a weekend emergency room visit.

A tiny device implanted in the patient’s pulmonary system is monitored by a special portable pillow that transmits data on the patient as they rest or sleep. The data requires as little as 15 minutes to collect, after which the patient is free to sleep as they like, using their own pillow.

The program also provides a steppingstone to another valuable service offered at Mount Sinai South Nassau: cardiac rehabilitation. While many patients with heart failure are afraid or unable to exercise, an objective of the program is to enable them to attend cardiac rehabilitation and improve their exercise capacity.

“Our goal is that every patient who graduates from the Cardiac Wellness Program can be referred to the cardiac rehabilitation program within five to six weeks,” Dr. Stevens-Haynes says.

After patients participate in regular exercise, clinicians recheck their ejection fraction; some may turn out not to be in permanent heart failure, and even those with ongoing heart failure can rebuild stamina, often enabling them to return to work or recreational activities.

“Patients can receive complete heart failure management at Mount Sinai South Nassau. We offer a comprehensive outpatient program, and the presence of an advanced heart failure specialist allows them full continuity of care.”
— Pilar Stevens-Haynes, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Director of Noninvasive Cardiology at Mount Sinai South Nassau

Nuanced Approaches to Complex Conditions

Heart failure is rarely a standalone condition. The groundbreaking Cardiovascular Health Study, funded by the National Heart, Lung, and Blood Institute, found that 60% of patients followed had three or more comorbidities, whereas just 2.5% had no additional health conditions. Many experienced difficulties in performing activities of daily living, and 17% had cognitive impairment. Comorbidities included diabetes, chronic kidney disease, cerebrovascular disease, hypertension, peripheral arterial disease and atrial fibrillation.

Many of these conditions present challenges to surgical management. Both in-hospital complication rates and long-term survival are worse among heart surgery patients who have diabetes, for example, and hospital stays for these patients tend to be longer and more expensive.

The experts at Mount Sinai South Nassau bring deep experience to optimizing care for patients who have heart failure coupled with other conditions.

“Patients come to us with a whole host of problems,” explains Noah Moss, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai, Medical Director of Mechanical-Circulatory Support at Mount Sinai Heart and a liaison with Mount Sinai South Nassau. “Some of their conditions have led to heart disease and some are unrelated to their heart failure, but with recent improvements in surgical technology and medical care, we can offer procedures even to the sickest patients who are suffering with disease of other organs — disease that at one time would have been prohibitive of cardiac intervention.”

On-Site Heart Failure Specialist

Patients in the Cardiac Wellness Program who could benefit from additional leading-edge heart failure therapies can now receive care locally from a fellowship-trained heart failure specialist as well.

Advanced heart failure cardiologist Noah Moss, MD, Assistant Professor of Medicine at Icahn School of Medicine at Mount Sinai and Medical Director of Mechanical-Circulatory Support at Mount Sinai Heart, has extensive training and experience in managing complex heart disease, including transplant and ventricular assist devices. Even as an undergraduate, he completed a specialty year in medical research. After earning his medical degree, Dr. Moss completed an extra fellowship year devoted to heart failure, and for four years he has served as an attending advanced heart failure cardiologist at The Mount Sinai Hospital. Board-certified in internal medicine, cardiovascular disease, and advanced heart failure and transplant cardiology. He now works as a liaison with Mount Sinai South Nassau.

Dr. Stevens-Haynes and a patient discuss the transmitter implant and diagnostic pillow.

“In the past 20 years, the treatment of heart disease has become increasingly complex, with more options available for patients — even those with very advanced disease for whom we previously really had no treatments,” Dr. Moss says. “At Mount Sinai, we have world-class experts in every area of cardiology, so we can offer the most sophisticated treatments.”

Educating patients about leading-edge therapies that can extend the quality and length of their lives — and about the time frame during which those therapies are most beneficial — is one of the areas in which Dr. Moss’ presence at Mount Sinai South Nassau makes an enormous difference.

“We want to identify those patients who need advanced care and help them make the transition to Mount Sinai to have the procedure or treatment performed,” he says. “Subsequently, patients can receive longitudinal follow-up care at Mount Sinai South Nassau.”

Staff of the cardiology team support Drs. Moss and Stevens-Haynes in the heart failure program.

Advanced Treatments

Heart failure encompasses a wide spectrum of structural heart conditions, including valve disease and cardiomyopathies of all kinds, Dr. Moss notes. That makes an arsenal of high-level treatment options essential.

For patients at Mount Sinai South Nassau for whom heart transplant is indicated, The Mount Sinai Hospital fields a comprehensive heart transplant program staffed by specially trained surgeons, nurses and technicians. The program also engages in cutting-edge research and offers access to experimental therapies, enabling more patients to live to transplant. One example is the Total Artificial Heart, a mechanical assist device supplanting the patient’s own ventricles with pneumatic circulatory support.

Other patients benefit from a left ventricular assist device (LVAD), a small, implanted heart pump that may serve as a bridge to transplant or a destination therapy for patients with heart failure. The LVAD pumps blood from the left ventricle directly into the aorta, dramatically improving blood flow from the heart for patients whose heart cannot do this on its own. It is managed by a small controller and power source worn outside the body. Dr. Moss’ skill in these areas is enhanced by the fact that he has performed research into factors affecting both heart transplant and LVAD success.

Patients who have received either a heart transplant or LVAD require regular follow-up and lifelong management. At Mount Sinai South Nassau, these patients can receive ongoing care in or near their home communities.

“We are integrating specialized services to make them available to patients on Long Island,” Dr. Moss explains. “It can be burdensome to travel to Manhattan regularly, so we are making a much broader range of services accessible at Mount Sinai South Nassau.”

The presence of an advanced heart failure specialist at Mount Sinai South Nassau also has the potential to lower emergency room readmission rates and hospitalization rates. Patients with low ejection fraction, Dr. Stevens-Haynes says, are frequently in and out of the hospital. Now, instead of going into the city for transplant evaluation, these high-risk patients can be identified locally while they are in the care of Mount Sinai South Nassau specialists and receive initial evaluations on-site.

Patients with heart failure also benefit from rigorous collaboration and coordination of care between the specialists at Mount Sinai South Nassau and referring physicians, according to Dr. Moss.

“My colleagues and I work alongside referring providers, supporting them with their patients and offering advice and expertise,” he says. “It’s really important that patients feel very comfortable with their own cardiologist or other referring physician. I am in continuous, close communication with referrers and work with them to support their patients’ health.”

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