CHF path cuts length of stay, saves $2,300 per case
By Kimberly Jungkind, RN, MPH
Rose Shaffer, RN, MSN, CCRN
Case Managers
Thomas Jefferson University Hospital
Philadelphia
Congestive heart failure (CHF) patients participating in a six-month case management pilot project at Thomas Jefferson University Hospitals (TJUH) in Philadelphia saved the hospital an average of $2,300 per case.
Length of stay (LOS) for case managed patients was 4.5 days while non-case managed patients had a 7.1 LOS. Hospital readmissions, averted admissions, and patient satisfaction data are still under analysis from the initial project, which ended in June.
TJUH, a 717-bed tertiary care university teaching hospital, implemented a pilot hospital case management program in June 1995 because of managed care's penetration in the Philadelphia marketplace. A multidisciplinary steering committee was appointed to establish the goals and priorities for case management, select the patient population to case manage, and develop a framework for case management.
The objectives of the hospital case management program were to:
* achieve a purposeful and controlled connection between the quality and cost of care;
* promote coordinated continuity of care for an entire episode of illness to decrease the LOS;
* examine resource utilization within an appropriate LOS;
* increase patient and family satisfaction;
* promote collaborative team practice among hospital disciplines;
* document outcome trends.
CHF patients were the first patient group to receive case management services because their complicated medical needs related to the program's goals and were of interest to hospital and physician leaders. To meet the objectives, a CHF critical pathway and other supporting documents were developed.
The five-day pathway was designed to incorporate the pre-admission and post-discharge phases of care. The path includes all possible points for a patient to enter the hospital system: from the physician's office, the emergency department (ED), or direct admission.
Additionally, the path provides a choice of locations for a patient admission: an intensive care unit or cardiac care unit, an intermediate care unit or a general medical unit. The family and internal medicine service groups agreed to have CHF patients managed as part of the pilot.
CHF patients for the pilot project were identified for case management services by numerous sources, including any professional allied health care service, as well as through daily computer-generated admission lists. Patients identified for the project were evaluated using the following exclusion criteria:
* aortic stenosis;
* recent myocardial infarction, but not within the last week;
* renal failure;
* pneumonia;
* cardiac dysrhythmias as the CHF primary cause.
CHF patients eligible for case management but not admitted to either the internal medicine or family medicine units served as a comparison group of CHF non-case managed patients to help evaluate the program.
Outcome and teaching objectives also are included on the path. Selected variances are identified within each column for all members of the multidisciplinary team to complete daily.
Other tools developed to enhance the case management process includes a patient pathway, standard orders for the first day of admission, a daily weight chart, and a detailed discharge instruction form. The standard admission orders can be adapted for each physician because they were developed simply as a guide.
Educational tools available include a patient teaching booklet entitled Managing CHF: Changes that You Can Make, a 12-minute videotape about CHF provided on the hospital education channel, and medication cards.
The patient path is given to the patient in the ED or upon any entry point in the health system. The path, written in an easy-to-understand format, is reviewed daily with the patient and family. Key illustrations are included to underscore the importance of self-management. For example, a salt shaker with a line through it and a step-on scale are included to highlight the importance of decreasing salt intake and monitoring weight daily.
Discharge instructions, which are compiled on a multi-page form, are shared with the home health department to assist in informing nurses about the patient's care. A copy of the instructions are sent to the department following the patient's discharge.
The framework for case management was developed using the continuum of care approach. Three small work groups were formed: a critical pathway/variance work team, a communication interface work team, and a program evaluation work team.
A project director for the case management program and two clinically based case managers with master's degrees coordinated the successful pilot. The collaborative approach of the multidisciplinary team was key to the implementation of the program.
The critical pathway/variance work team met twice a week for several weeks in order to draft the path. This was a multidisciplinary effort with key physician leadership present at every meeting. Although critical pathways already existed within the institution, this was the first path developed under the auspices of case management. The CHF path team also was the first team to have resident-level medical staff involved in the development process.
An extensive educational effort was undertaken to inform all disciplines about the pilot case management project. Program information was given to all departments in the form of a one-hour presentation or informal communication. Case managers conducted many of the educational sessions, but members of the critical path/variance work team presented sections of the session when possible.
The multidisciplinary involvement during the educational phase emphasized the importance of a team effort.
Results of the first six months were summarized in a report detailing the cost savings and lower resource utilization rates. Administrators decided to continue the program based on the results of the pilot program. Information was gathered from the CHF case-managed group and CHF non-case-managed comparison group. Specific results were measured for:
* LOS;
* resource utilization;
* cost/charge per case;
* patient satisfaction;
* clinical and non-clinical variances;
* insurance data;
* DRG coding analysis;
* patient perception of their functional status using the Short Form (SF) 36 questionnaire.
Resource utilization rates, for example, were lower for case-managed patients compared to non-case-managed patients. Blood collection rates averaged 12.2 for path patients compared to 23.1 for non-path patients.
Despite the high level of success, several areas for future case management redesign were identified during the pilot. Limitations of the case management pilot included a lack of computerization of patient records, secretarial support, variance tracking, concurrent medical record chart coding, centralized patient notification system, and daily program coverage.
[Editor's note: For more information , contact Kim Jungkind or Rose Shaffer at: Thomas Jefferson University Hospital, Case Management, 111 S. 11th St., Room 1900 Gibbon, Philadelphia, PA 19107-5098. Telephone: (215) 955-8946.] *
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