Almost 6.5 million Americans over age 20 are living with heart failure. Each year, about 960,000 more people are diagnosed.

Heart failure happens when the heart can't pump enough blood and oxygen to the body. This doesn't mean your heart has stopped or is about to stop. But when blood flow is too low, the body’s organs may not work properly, which can lead to serious health problems.

Doctors recommend that people with heart failure see a health care provider within a week after being discharged from the hospital. These patients often need regular checkups to adjust medications, check their symptoms, do lab tests and get help with things like prescription refills or other treatments.

But many people don’t have easy access to health care.

“One of the challenges we see with heart failure patients admitted to the hospital is the transition of care after discharge,” explained Martin Cadeiras, clinical professor of cardiovascular medicine at UC Davis Health. “We take care of these patients during their hospitalization, but once they’re discharged, continued follow-up and optimization of care are critical. There’s a significant group of high-risk patients — those with a higher likelihood of returning to the emergency department, being re-hospitalized, or even dying from heart failure — who fall through the cracks after discharge.”

To help fix this problem, UC Davis Health and WellSpace Health have teamed up to open a heart failure clinic at WellSpace’s Oak Park health center. WellSpace is the largest community health system in the Sacramento area. The clinic is part of the Specialty Connect program, which brings UC Davis Health specialists into community clinics where they provide care to historically underserved populations.

“This collaboration brings specialty cardiology support into the primary care setting — improving care access and outcomes for high-risk patients in the community.”—Martin Cadeiras

“This collaboration brings specialty cardiology support into the primary care setting — improving care access and outcomes for high-risk patients in the community,” added Cadeiras. “This is one way we can address the gap in care for patients who do not have access to specialized heart failure services.”

How the program works

To start the program, physician assistants from WellSpace Health trained for eight weeks at the UC Davis Heart Failure Clinic. They observed care in the hospital, worked in the clinic and teamed up with nurses and pharmacists.

After providers were trained, the new heart failure clinic opened at WellSpace Health’s Oak Park Community Health Center. Cadeiras and the physician assistants worked together to lead the patient care team.

At the clinic, patients get checkups and follow-up care. Patients can also take part in programs to manage blood pressure and learn more about their health and self-care. A medical assistant, pharmacist and health educators work together to make sure patients get lab work done, stay in touch with their primary care doctor and understand how to manage their heart failure.

“Within the heart failure clinic, we're able to provide high-quality and equitable care to all patients, no matter how sick they are,” explained Christina Golden, a physician assistant at WellSpace Health. “By closing gaps in care and making it easier to get help, we’re able to support the whole community and treat even the most complex patients.”

More clinics, more access

A second heart failure clinic has now opened at WellSpace Health in Citrus Heights, staffed by a WellSpace Health care team. Any adult patient with Sacramento County-assigned Medi-Cal is eligible to receive care at one of the heart failure clinics. So far, more than 200 patients with serious heart failure have been helped by the program. 

“By working together and providing high-quality services, we’re making it easier for people to get the care they need,” said Janine Bera, chief health officer at WellSpace Health. “Our goal is to help everyone — no matter their situation — live a healthier life through smart, patient-focused care.”

“This is another example of UC Davis Health’s success in expanding equitable cardiovascular care in the Sacramento Region,” said Thomas Smith, chief of cardiovascular medicine at UC Davis Health. “We strongly believe in the power of collaboration within and across health systems to improve the health of our patients. This care delivery model also lends itself to wider adoption by other health systems that serve patients facing similar challenges.”