St. James working to improve heart health and advance health equity to support Million Hearts® 2027
Keith Miller has been learning to enjoy life by staying on top of a new health challenge. To keep healthy, every day he uses an app called MyChart to enter his essential health data. This information is shared with his care team at St. James Hospital, who review his numbers to ensure he is on the right track.
"It's really nice to have somebody looking out for you," said Miller, a Butte resident and middle school administrator.
His 4-year-old granddaughter sits on his lap, feeling the defibrillator under his chest. He told her it's his battery pack, sending her twin brother to the kitchen to grab a 9 Volt battery. That brought a warm laugh from Miller. He shows the kids how he checks his blood pressure.
Every day, Miller weighs himself, checks his blood pressure, and plugs the numbers into the MyChart app on his phone. It adds some extra steps to his daily routine but is more accessible than going to the doctor's office.
Heart failure is a very hands-on diagnosis for providers. The model of care set up at St. James is meant to be as remote as necessary.
"MyChart has been great, especially if patients miss appointments. As we looked through the winter months, we had people that couldn't get in, so we had the ability to still provide the same care we would provide in clinic via remote," said Marcus Paske, a clinical pharmacist in ambulatory care at St. James. He helps manage chronic diseases like heart failure, diabetes, hypertension, and patients on blood thinners.
Miller was initially hospitalized in April with pneumonia and parainfluenza. During the workup, caregivers discovered he had a new cardiomyopathy or a new diagnosis of heart failure.
Becky Wozniak, NP, says that's an overwhelming diagnosis.
Wozniak sees patients in the outpatient cardiology clinic, caring for patients referred by other providers with new cardiology problems and all the patients hospitalized with cardiac issues. She also helps with chronic care management and any long-term cardiology problems.
"When someone has heart failure, it requires a lifestyle change that Keith just jumped right in," said Wozniak.
He is very diligent about checking his blood pressure and weight and uploading it into his chart, which allowed me to see that in real time.
Patients need to keep close tabs on their blood pressure and their daily weight because those numbers can indicate when heart failure is taking a turn for the worse. Providers are not looking at their weight to catch them eating cookies or fast food.
"If we can catch that in those first three to five pounds, a lot of times we can make changes with medications over the phone to get him right back on track and avoid him having to come into the hospital for more care. And Keith really stays on top of that. He is very diligent about checking his blood pressure and weight and uploading it into his chart, which allowed me to see that in real-time. And then between Marcus Paske and I, we could phone him when needed, so he didn't have to go back to the hospital for any further care," said Wozniak.
Once a week, Paske and Wozniak check Miller's numbers to make sure he's getting adequate doses of his medications that are not making him too dizzy or sending his blood pressure too low. They also make sure Miller can continue with his life as normally as possible without the interruption of another hospitalization.
This "Hearts in the Mountains" initiative was set up at St. James to improve access to care for people with heart failure living in rural communities in Southwest Montana. In February, the program received a huge boost when Million Hearts Health Equity Implementation awarded St. James $50,000.
Since this implementation, readmission rates at St. James have dropped significantly — from 30 percent in 2022 to 13.25 percent so far this year. Furthermore, there were no readmissions in three of the previous five months.
"The best part is we reduced readmissions, and that's the ultimate goal -- to improve our community's life," said Paske. "It also highlights the team-based care model. Heart failure is probably one of our most complex things that we manage, and we know more about it now than we knew five years ago. The team-based care approach is the best because it just gets the patients so many different people that know different facets of their disease. When they work together, we truly make people better and healthier."
Paske's clinical pharmacy team has expanded with two new clinical pharmacists, allowing them to see more patients.
"We are seeing more of these patients before they get admitted. Some of the downhill effect from the program is we know that if we get more people involved earlier, we're able to keep them out of the hospital. So that's a huge benefit. That's kind of been off to the side of the actual data collection of readmissions," said Paske.
Miller spends about 10 minutes daily checking his blood pressure and weight, then sending the numbers to Paske and Wozniak. He says it's so quick that some days, he doesn't notice it anymore.
"The whole experience has been life-altering, but (going into the clinic more often) would've been an even bigger shift. I've still been able to go to work, still been able to enjoy my grandkids —which is my No. 1 priority. And so it's really the cool part of it that I can get back into life a little bit faster."
Miller also added a walking routine to his day. All his lifestyle changes and his medications have been working. And his heart is getting even stronger. He hopes that continues.
"The thing I appreciate that's come out of this whole thing is, I've had a chance to really prioritize what's important in my life, and time with my grandkids is the most important. I'm pretty lucky right now."