Inova accelerates care transformation for heart failure

Heart failure is a major focus for Inova Schar Heart and Vascular’s care transformation efforts. This involves collaboration across multiple domains to implement a deliberate and thoughtful guideline-directed therapeutic approach to ensure every patient with heart failure receives the best care possible. The result is a system-wide comprehensive care model for heart failure.

“We looked at the condition of heart failure holistically, focused on areas where there is clear evidence as to which care practices improve outcomes, and then built high-reliability checklists and support tools within our electronic health record around those practices,” said Stuart E. Sheifer, MD, FACC, Medical Director for Care Transformation, Inova Schar Heart and Vascular. 

These transformation efforts are not the result of adopting a particular technology or vendor solution. Rather, the transformation taking place is the result of a strong, collaborative team coming together to assess the current state, identify goals that would significantly impact heart failure care, determine a plan to get from current state to goal state, and execute that plan. The team deployed technology strategically, but the ingredients that make the care transformation truly effective are expertise, teamwork, and focus.

The heart failure transformation team included multidisciplinary leaders from several areas including advanced heart failure, informatics, quality, and analytics.

“Heart failure is a complex chronic disease in which patients have multiple touches with the healthcare system, and appropriate management requires a multipronged approach to improving care for these patients at many levels,” said Mitchell Psotka, MD, PhD, Section Chief, Heart Failure and Transplant at Inova Schar Heart and Vascular. “The goal is to create a program through which those patients are all prescribed as many of the appropriate therapies as possible and are treated in the most evidence-based way.”

Care pathways standardize key moments in a heart failure patient’s journey

“We have leveraged different tools to identify opportunities to improve heart failure care for all patients, with particular attention to specific, pivotal points in their heart failure journey,” said Carolyn Rosner, MSN, NP-C, MBA, Senior Director of Inova Care.

For example, when a patient is admitted to the hospital with decompensated heart failure, many steps need to be taken to ensure care excellence every time, for every patient. That’s why, in 2024, Inova’s team developed a care path for heart failure in Epic, the health system’s electronic health record. It prompts clinicians at every point across the inpatient journey – whether it is during the ED evaluation, the admission process, or on daily hospitalist and cardiologist rounds, to provide consistent care using guideline-directed diagnostics and medical therapy.

Across deployment of the comprehensive care model, there have been consistent significant trends showing improvement in utilization of guideline-directed medical therapy.  This is true for prescription of each indicated medication at hospital discharge, both for heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF).  Most notable is the prescription of all four guideline-directed pillar agents for the management of HFrEF at discharge, which now sits at 42.6%. This performance is favorable relative to national benchmarks and comparable to the levels achieved in landmark implementation science trials in this population of patients.

The team continues to add additional improvements to the care model, expanding coordinated care at critical moments throughout a patient’s journey with heart failure. Prominent within those are tools built to identify opportunities in clinic to optimize guideline-directed medications, prompt providers, and expedite ordering in the outpatient setting.

Much of the work focuses on ensuring the documentation and process needed to consider and implement changes are clear and consistent across care sites, so all providers and care team members know what actions to take for  patients with heart failure and have the tools they need to do so.

Connecting the dots across the hospital

Because guidelines are only useful if patients can get the recommended medications, the team is launching projects in coordination with the pharmacy. Pharmacists will work with the care team, navigators, and outpatient pharmacies to address admission and discharge medication reconciliation, the role of each medication, scheduling, and working to overcome any additional barriers. Strategies include inpatient pharmacist consultation on high-risk patients with heart failure, as well as implementation of pathways to support patient access to high-cost medical therapies.

Care protocols also emphasize other often-underutilized but beneficial services for patients with heart failure, such as the health system’s cardiac rehabilitation programs. “Cardiac rehabilitation is a wonder drug with zero toxicity,” Dr. Sheifer said. “It improves survival and reduces hospital readmissions with no negative impacts.” By incorporating an order for cardiac rehab into the checklist used at time of discharge, Inova has increased utilization of cardiac rehabilitation dramatically in the last five years.

Smart technology

The team continues to use artificial intelligence tools within Epic to look at heart failure patients’ medications and prompt providers to consider adding medications or adjusting doses, to optimize care to match best evidence.

“Our goal, broadly, is to improve the journey for patients with heart failure from the moment of admission or the moment of emergency department presentation to thriving in the outpatient world,” said Dr. Psotka. “Along the way, we’re making sure that they are being set up for success by facilitating appropriate care using the electronic health record to nudge all the clinicians who touch that patient to do the right thing.”

Another example of leveraging AI’s involvement is in helping to determine when a patient’s heart failure is progressing to a point where an advanced heart failure physician’s involvement would be beneficial. The symptoms of heart failure progression can be subtle, and too often, patients are not referred for evaluation by an advanced heart failure cardiologist at a point where they can benefit from all treatment options. AI tools prompt clinicians to refer for consultation at the right time.

Complementary high-impact improvements

Inova’s Urgent Heart Failure Clinics, available at Inova Fairfax, Inova Loudoun, and Inova Mount Vernon hospitals for several years, provide an alternative to the emergency room for outpatient access to IV diuretics and laboratory testing for patients with known heart failure and worsening or decompensated heart failure symptoms, despite being on pill diuretic medications.

Utilization of these clinics increased nearly 300% between 2022 and 2025, and these clinics have helped patients avoid unnecessary hospitalizations.

Over 90% of patients were discharged home from the urgent heart failure clinics in 2025, instead of being admitted to the hospital:

• Inova Fairfax Hospital: 95%
• Inova Loudoun Hospital: 97%
• Inova Mount Vernon Hospital: 92%

And 30 days later, the majority of patients still had not needed to be hospitalized:

• Inova Fairfax Hospital: 62%
• Inova Loudoun Hospital: 80%
• Inova Mount Vernon Hospital: 59%

“We’ve done a lot of awareness building around our urgent heart failure clinics,” said Dr. Sheifer. “Our goal is to identify early decompensation, so these patients receive care in ways that avoids an emergency room visit and hospitalization.”

At every step of the heart failure journey, the team at Inova works together to support clinicians in making the best choices for patients. This team views the work as an evergreen, enduring mission, with a focus on continuous improvement and the provision of world-class patient-centric care.

Connect with Drs. Sheifer and Psotka and Carolyn Rosner, MSN, NP-C, on Doximity.