Combination of strategies cuts CHF readmissions
Sickest patients are targeted for visits, phone calls
In the first 18 months of its congestive heart failure (CHF) disease management program, Harvard Vanguard Medical Associates in Boston achieved a 77% reduction in hospital readmissions for the targeted patients.
The program, which includes a combination of clinic visits, education, and telephone calls, is designed to serve the sickest patients — those who are likely to be rehospitalized.
The initial recruitment begins in the hospital for patients with primary or secondary diagnosis of congestive heart failure (CHF).
"The ideal time to catch them is when they are being discharged for acute exacerbation. They have a higher motivation to change their behavior at that time," says Diane Gilworth, RN, MPH director of the program for Harvard Vanguard, a fully capitated 550-physician multispecialty group practice.
Gilworth and two nurse practitioners manage the care of 180 patients. Since the program started 2½ years ago, 245 patients have enrolled.
In the past, most patients were discharged from the hospital with little or no education about their condition. "They didn’t understand their condition and symptoms. They were taking unfamiliar medication and didn’t have a good sense of what their diet would be. It wasn’t uncommon for them to end up in the hospital a month later," Gilworth says.
The CHF staff co-manage the care with the seven cardiologists and the primary care physicians within the Harvard Vanguard organization. The CHF practitioners try to optimize the patient’s medication, looking beyond the CHF at comorbidities such as diabetes and chronic obstructive pulmonary disease (COPD).
"Our relationship with the primary care physician is critical. We couldn’t run the program without close collaboration with them. We have taken [away] their burden of frequent direct interfacing with the patient," Gilworth adds.
For instance, if the CHF staff find that the patient’s lipid levels are elevated or that they’re using more puffers for COPD, staff refer the patient to the primary care physician.
The CHF team also makes sure patients are on the appropriate medication as outlined by consensus guidelines. By optimizing the use of diuretics, Gilworth and her staff try to get patients down to what an estimate of what their dry weight should be.
"If we can get patients to that dry weight, their exercise tolerance improves. They begin to work longer. We’ve seen substantive improvement in the distance walked for many patients after their medications were optimized," she adds.
When patients have become stable, the CHF team usually passes them on to the case managers in each center. The patients still receive a monthly surveillance call designed to catch any significant changes in health status.
The Harvard Vanguard staff based its disease management program on Agency for Health Care Policy and Research guidelines and elements of other disease management programs in other parts of the country.
"We looked at what other providers were doing where there is a large HMO penetration, and we picked elements we thought were most important and would fit with our culture. It’s not a one-size-fits-all," Gilworth says.
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