A program that changed the way heart attacks and strokes are treated in rural Kansas will come to an end this year. But advances made by the Kansas Heart and Stroke Collaborative should continue to benefit many of the state's residents.

Bob Moser, M.D., the collaborative's executive director, said he gets a couple of emails per month from participating providers describing how the effort led to a positive outcome for a heart attack or stroke victim.

"Now they're back in the community, back to work, with no residual effects where previously they would have been disabled," Moser said. "They're seeing the great outcomes because of what they're doing out in the communities."

The collaborative was launched in 2014 with a three-year, $12.5 million grant from the Center for Medicare and Medicaid Innovation. Heart attack and stroke are two of the state's five leading causes of death, with greater rates of mortality and hospital readmissions experienced in rural areas.

The program started as a partnership between the University of Kansas Hospital, the Hays Medical Center and 11 critical access hospitals in northwest Kansas. Today, it's active in 51 counties spread across the state.

"The expansion has been kind of amazing," said Moser. "We were hoping in year two we might double. We've essentially quadrupled."

The program has several components. The first was analyzing where participants were in their care of heart attack and strokes compared to recommended protocols.

"We saw a lot taking 15 minutes to get an EKG (for a patient) when one was ordered," he said. "Why's it taking so long when the goal is five minutes?"

Having a nurse qualified to obtain the EKG, blocking out personal information for HIPAA compliance, and sending it to the on-call provider by text after taking a photo with a smart phone or iPad was one way of meeting that goal.

Many rural sites were challenged to get patients to a cat lab within 90 minutes of first contact, which is the national benchmark. Less than three percent of eligible patients received thrombolytic therapy - clot-busting drugs. Collaborative members have recorded significant improvements in both of those areas.

The collaborative also installed two-way telemedicine portals in the emergency rooms of the original participating hospitals, allowing nurses, physician assistants and physicians to consult specialists for help in diagnosing and treating patients. This system also assists with arranging for medical transport to the next level of care while the providers can remain engaged with patient care.

"You can activate it for any (medical issue) but what you really want to use it for are strokes and heart attacks," Moser said.

"We're hearing great feedback," Moser added. "A few that weren't originally 100 percent thrilled to have somebody looking over their shoulder now think 'Hey, this is great.'"

Earlier this year, Moser estimated that more than 5,000 Kansans have been treated using protocols adopted by the collaborative's partners - a number that grows daily.

Yet another part of the collaborative was putting in place a regional transitional care management system, to help people who've been treated and released from larger health systems returning to their rural communities.

"Often they come home and find it challenging to deal with what acute event they just went through, let alone all the new medications and instructions," Moser said.

This transitional care management helps them get started off right and plugged back into their local system of care.

The collaborative model includes several managers, or local health coaches, who follow up with patients after the transitional care management. There are more than 30 full- and part-time health coaches who work in rural communities, keeping in touch with their clients monthly. The coaches focus on heart and stroke patients at present, but also adding those who have at least two chronic diseases, such as diabetes, COPD or high blood pressure, as well. Moser said there were significantly fewer heart attacks in the counties served by original collaborative participants in 2016 compared to 2013, according to the data we have been tracking.

Jennifer Dreher, a registered nurse from Hays who serves as a coach for Ellis County, said it's not uncommon for her to find clients who are taking different medication, or different amounts of medication, than prescribed by their physicians. Many are too poor to afford their medication while also paying for housing, food and transportation. She tries to get them assistance in all those areas and more.

"Maybe it's helping them get a shower chair, wheelchair or cane," she said. "The patients like to have you on board, to have someone on their side to help them get resources they didn't know were out there."

Getting clients to reduce smoking and other risky behavior is also stressed. Over 1,000 Kansans have been served by the transitional care management system.

Reducing health care costs is another goal of the collaborative.

"The goal of reducing total cost was three percent," Moser said. "We're above that."

The collaborative's grant was initially set to run out in August 2017. However, because some of the money hadn't been spent by that time, it applied to extend the life of the grant through 2018. Other conditions were added to this work besides heart attacks and stroke because of the success the collaborative was seeing. For example, sepsis was a condition added in 2016 and this year acute heart failure, palliative care and trauma are being developed and piloted. The Kansas Heart and Stroke Collaborative has been rebranded for this ongoing effort as The University of Kansas Health System CARE Collaborative effective Sept. 1, 2017.   

Part of the collaborative's original mission was to find a way to become self-sustaining financially. As the data showed improved outcomes with heart attacks and stroke, the collaborative's Finance/Administration Committee recommended consideration of Centers for Medicare and Medicaid Service's Medicare Shared Savings Program, a no-risk Accountable Care Organization, or ACO. To accomplish this, a new legal entity had to be created, which began the Kansas Clinical Improvement Collaborative (KCIC). Along with some of the Heart and Stroke members joining this ACO, KCIC also became a listed Patient Safety Organization. This allows the collaboratives (both the KCIC ACO, and the KUHS Care Collaborative) to work with the local health systems, EMS, and long-term care facilities in doing quality improvement work and protecting the peer review process.

Moser was well suited to promote the collaborative around Kansas. The native of Tribune, Kansas, is a KU Medical School grad, former Kansas Family Physician of the Year, one-time director of the state health department and - briefly - member of the KU School of Medicine-Wichita faculty. As facilities beyond the original participants expressed interest, collaborative members travelled to those facilities to conduct boot camps for training in recommended protocols.

"It's kind of exciting," Moser said. "I think they see an opportunity to learn best practices and learn from each other."

Expanding the collaborative has also led to a greater accumulation of data about health care and outcomes in the state.

Looking down the road, Moser thinks the collaborative is an example of how KU's medical research can help Kansas providers and our communities across the state.

"How we do capitalize as an academic medical center, working with regional health systems to rural health systems to move new evidence-based guidelines and cutting-edge treatment to quicker adoption in every day practice? We believe the Kansas Heart and Stroke Collaborative model is a great way to do that."

Assessing the collaborative's first three years, he said, "If our goal was to improve outcomes and quality of care for heart attack and stroke patients in our participating communities, we're certainly seeing that."