About 95% of medical call centers nationwide use the Schmidt-Thompson protocols, but in 2024, WellSpan Health leaders opted to create their own protocols for heart failure patients.
“We recognized that protocols like the Schmidt-Thompson were designed around safety,” James Harvey, MD, vice president and chief medical officer of the heart and vascular service line at the York, Pa.-based system, told Becker’s. “They default to sending people to the emergency department, which is rarely wrong from a safety standpoint. But from a population health standpoint, there’s room for improvement.”
Traditionally, when a patient calls in for shortness of breath, they are immediately referred to the ED. However, patients with heart failure regularly experience shortness of breath, and it does not always require emergency care.
“The protocol doesn’t differentiate between someone with chronic heart failure and someone without it,” Brandon Danz, PhD, WellSpan’s vice president of population health, told Becker’s. “Heart failure is low-hanging fruit when it comes to identifying opportunities for population-level improvement.”
Dr. Danz’s population health team and Dr. Harvey partnered to create new protocols for heart failure patients that would cut preventable hospitalizations.
First, they reviewed admissions across six WellSpan hospitals from July 2022 to June 2023 and found that 93% of heart failure-linked hospitalizations were potentially avoidable. That represented $27 million in cost of care.
“Evidence shows that patients with a known diagnosis of congestive heart failure who meet certain criteria can be safely assessed and treated in an outpatient setting, as long as you don’t wait too long,” Dr. Harvey said.
With this in mind, Dr. Harvey and the population health team created a zone-based tool to assess the right care setting for heart failure patients: the green zone for patients who can do their usual activities, the yellow zone for patients who are symptomatic but not in distress, and the red zone for patients with severe symptoms that require immediate attention.
Most patients calling the nurse triage line fell into the yellow zone, Dr. Harvey said. Leaders developed a new set of protocols and embedded them into the triage workflow. Now, when someone calls with shortness of breath and has a diagnosis of heart failure, the system prompts nurses to ask questions that align with heart failure-specific criteria. Based on the answers, nurses can determine if the patient qualifies for outpatient or ED care.
“The next step was access,” Dr. Harvey said. “If someone qualifies for outpatient care, where do they go? Ideally, their primary care physician or advanced heart failure clinic, but access varies by region.”
To solve this, WellSpan created a step-down pathway that encourages patients to try primary care first, then a heart failure clinic, then urgent care and finally the ED if they are unable to get into any of the first three facilities.
WellSpan launched the pilot in mid-2024, which included training patients and physicians on the zone tool, retraining triage nurses and embedding automated prompts. In the first year, the changes showed significant results for hospital operations and patient care.
- More than 80% of callers with heart failure fell in the yellow zone.
- About 92% of triaged patients with heart failure were managed in an ambulatory setting.
- Almost 85% of patients avoided an ED visit within 24 hours. Of patients directed to outpatient care, less than 10% ended up in the emergency department within 24 hours.
- The protocols cut potentially avoidable admissions by 11.2% and saved more than $3 million in total costs of care.
The system also saw better care outcomes and improved patient experience, Dr. Danz said.
With a successful pilot program, leaders are looking to make tweaks to further access and bring a similar protocol change to other diseases.
Dr. Harvey said WellSpan is looking to cut preventable hospitalizations and costs further by bringing more heart clinic care to patients through telehealth and algorithm-driven care pathways for primary care physicians.
The system also is exploring a similar approach for patients in oncology, end-of-life care and other chronic conditions.
“Some systems hesitate to reduce admissions for fear of losing revenue,” Dr. Danz said. “But CMS is pushing value-based care and transparency. Systems that provide the right care in the right setting will earn patient loyalty and long-term sustainability.”
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