Calls after discharge cut readmissions, LOS
Hospital CMs follow patients for up to six months
A telephonic case management program for heart failure patients who have been discharged from New Hanover Regional Medical Center has resulted in a 77% decrease in readmissions and cut a day off the average length of stay for heart failure patients who are rehospitalized.
New Hanover Regional Medical Center's heart failure program was begun in 2002 and expanded in 2003 with funding from the Cape Fear Memorial Foundation, according to Pam Hagley, RN, BSN, MSHA, ACM, director of clinical resource services for the Wilmington, NC, tertiary care hospital.
Two case managers, Renee Slater, RN, and Denise Phillips, RN, manage the care for 300-400 heart failure patients at one time. Their goal is to get every heart failure patient who is discharged from the hospital involved in the program.
The case managers call CHF patients a few days after discharge, conduct an assessment of the patient's condition and knowledge about the disease, and develop a care plan.
The case managers have access to the patient records on the hospital's computer system. Physician order sheets and progress notes are scanned into the computer within a few days after discharge.
"We can look at the patient information and have a good idea of what happened when they were in the hospital and what the discharge planners determined about their resources at home," she says.
It's important to follow up after heart failure patients are discharged to make sure they understand their disease and their treatment plan.
"Heart failure patients get a lot of information when they're in the hospital, but they're sick and they don't remember it all. Our goal is to help them learn to manage their condition and to understand when they need to call the doctor," Slater says.
Medication compliance
Making sure the patients take their medication as directed is the case managers' top priority.
"A lot of times, heart failure patients aren't taking the right medication when they come home. The physician may change their prescription for a beta-blocker and they may be taking both the old and the new medicine," she says.
When patients can't afford to buy their prescriptions, the case managers help them sign up for programs that provide free or reduced-price medications. They help eligible members sign up for Medicaid and other members sign up for Medicare Part D.
The case managers go over insurance, family support, activities of daily living, and work with patients on smoking cessation if they need it.
They give the patients information on low-salt diets and teach them how to read labels to determine the sodium content. They mail them low-salt recipes and samples of salt-free seasonings.
They can send scales, provided by the hospital's auxiliary, to patients who can't afford them. They make sure that the patients who are newly discharged go to follow-up visits with their physicians.
"A lot of what we do is listening. These patients are frustrated with their condition. When they're in the hospital, they're sick and they can't remember everything they were told. Many of them are afraid to call the doctor when they have the early warning signs," Slater says.
The case managers call many of the patients once a week for the first month, then taper off, following them for up to six months.
"With every phone call, we reassess when we need to call again. The care plan for a patient could change every time we talk to them. It depends on how well they are progressing," Slater says.
At the end of six months, patients are discharged from the program if their case manager feels they can manage their care on their own.
The key to helping patients keep their condition under control is making sure they know the early warning signs and when they should call their physician, Slater says.
"Most of the time the reason patients come back is that they don't understand something they can do at home, like weighing daily or sticking to a low-salt diet," she says.
It's a challenge to convince patients that they will have heart failure for the rest of their lives and that even if they stay on their medication and do everything they're supposed to do, they may have problems in the future, Slater adds.
"We have patients who have very little education and those who are highly educated and it's across the board. Most people don't understand what heart failure is," she says.
People with heart failure feel powerless in the beginning, Slater points out.
"It's scary when they come to the hospital and can't breathe, and when they go home they are afraid it will happen again. They need to be walking and doing things to strengthen their heart, but they don't for fear that it will happen again," she says.
The case managers encourage members to keep weight journals if they're having trouble with fluid buildup and to keep up with what they're eating.
"They may think they're eating a low-salt diet but they are eating things, like cheese, that have a lot of salt," Slater says.
Many of the heart failure patients at New Hanover Regional Medical Center also have diabetes.
"We go over their medications and ask about their blood sugar along with their weight. Depression is fairly common among heart failure patients, and we make sure it's addressed," she says.
The telephone case managers work closely with the case managers and cardiac rehab nurses who work with the patients during the hospitalization.
"The nurses or inpatient case managers call if they have a concern about a patient or if a patient doesn't have insurance and needs assistance with medications. The doctors sometimes call and ask us to see a patient before discharge," she says.
The case managers call or send a fax to physicians when the patients have gained weight or are having other problems.
"The goal of the program is to empower patients to take control of their conditions.
"We want them to know what they should do a year from now when we're not calling them," Slater says.
About half of the patients hospitalized at New Hanover Regional Medical Center live in another county, too far to come for support groups or clinics. Telephone contact with the case managers is the only support they have.
"We're here for them when they have questions or concerns. Some patients don't have families and they call just to talk, like when the dog they had for 15 years died. That's a huge issue for them and they need someone to talk to," Slater says.
The heart failure program started as an outgrowth on the hospital's nurse call line, she says.
Initially, the nurses would call to reinforce the education the patients had at the hospital.
"The goal in the beginning was to help them understand some of the early warning signs so they would call their physician instead of showing up in the emergency room when it was too late to do anything but admit them to the hospital," Slater says.
In the beginning, physicians wrote orders referring their patients to the Heart Failure Telephonic Program.
"We tracked outcomes for six months prior to the program and six months after. The results were so good that the physicians no longer have to order the program," Slater says.
(For more information, contact Renee Slater, RN, e-mail: [email protected].)
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