Congestive heart failure patients needn’t mean money-draining care
Outpatient infusion relieves economic burden
Could there be an outpatient coronary care center in your hospital’s future? A number of such facilities have popped up lately around the country, and they’re serving to break the cycle of overutilization so common with refractory congestive heart failure (CHF). Resources are being directed at outpatient infusion therapy and strategies that identify problems before they create costly acute care episodes.
Cost Management in Cardiac Care looks at two such centers: The Heart Failure Center in Omaha, NE, has an exclusive referral arrangement with a cardiology practice. The Heart Failure Unit in Chicago depends upon referrals from local physicians. The goal of each facility is to prevent acute CHF decompensations and exacerbations that lead to inpatient admissions. Consistent, aggressive therapy, extensive education, and follow-up are keys to their success.
"Outpatient infusion programs are bound to be very successful," says Jackie Torpy, RN, BSN, coordinator of the Health Heart Institute’s Heart Failure Center located in the Alegent/Immanuel Medical Center in Omaha. "These patients need caring for, but we can’t afford to have them eating up all the hospital dollars. When one hears CHF, the automatic reactions are high dollars’ and very difficult patients.’ It doesn’t have to be that way. CHF doesn’t have to be a money-drainer. You can set up a cost-effective program and take excellent care of these patients."
Torpy, told CMCC that the center’s program has tracked notable savings in admissions, days in the hospital, and lengths of stay over its 21¼2 year lifetime. The staff ran an outcomes evaluation of 67 patients 44 men and 23 women ranging in age from 39 to 89 years before and after enrollment to gauge comparative numbers in those three factors. Sixty-eight percent of the study’s participants had CHF resulting from coronary artery disease, and half had advanced heart failure.
At the Alegent Heart Institute, before the program was initiated, the average length of stay for DRG 127 was 5.3 days. Sixteen months after the Heart Failure Center program was initiated, the average length of stay was reduced by one full day. Hospital admissions have decreased by 30%, hospital days by 42%.
The cost savings realized by the program are enormous, as well. Patients with CHF are typically admitted two to three times a year. Patients visit the Heart Failure Center clinic about 15 to 20 times a year at a total average cost of $2,000 less than one-fourth of the $9,000 that one admission for CHF usually costs.
Lori Heaney, RN, program coordinator of the Heart Failure Unit of the Cardiovascular Institute of Columbia Michael Reese Hospital in Chicago, was part of a team that ran an outcomes study of their facility on hospital admissions, lengths of stay, and emergency department (ED) visits.
The team followed 36 patients with severe CHF who were receiving milrinone or dobutamine. Ischemic heart disease was the cause of the CHF in 12 patients; in 11, it was idiopathic; in eight, it was hypertension, and in five, it was pulmonary hypertension. In the period before entry into the program, patients had 21 ED visits, 75 admissions, and 528 days in the hospital. After enrollment, there were 10 ED visits, 34 admissions, and 150 days in the hospital. (See chart, above.)
"If we’re reducing hospitalization admissions by 74% and days by 87%, the program is saving a whole lot of money," explains Heaney.
"All the outpatient infusion programs in the country are run a little differently," says Torpy. "Our program has a strong physician-patient focus and is suited to the type of care patients expect in the Midwest." Of the Health Heart Institute’s 13,000 patients, 65% are covered by Medicare. An additional 20% are covered by managed care plans, and 15% are fee-for-service.
The Heart Failure Center contracts exclusively with a 10-physician private cardiology practice, Heart Consultants, also a part of Alegent. (See chart illustrating center’s structure, p. 82.) Key personnel include an administrator who tracks costs, a cardiologist medical director, and a nurse program coordinator who functions as an extension of the medical director and implements the interdisciplinary aspects of the program.
Maintaining a continuum of care is a goal. To ensure consistency, each patient is assigned to one clinician group. All clinicians within a group follow the same protocol and use standardized clinic visit styles and paperwork. Protocols address both treatment and patient education.
As long as no contraindications exist, all patients with systolic dysfunction receive an angiotensin- converting-enzyme (ACE) inhibitor. Selected patients with severe CHF 80% to 85% of the center’s patient base receive IV inotrope (milrinone or dobutamine) infusions three times a week. (See tables showing inotrope and ACE inhibitor protocols, pp. 84-85.)
At first patients are seen weekly. Once stabilized, they come in at least every six weeks. The center employs a home health nurse who focuses on avoiding readmissions by checking the status of patients between clinic visits. She looks for decompensation and reports changes to the program coordinator so meds can be adjusted or a special visit to the clinic can be arranged.
The same home nurse sees patients on their regularly scheduled visits to the clinic so as to ensure consistency of care. A recent study showed that weekly home visits to patients with severe CHF reduce hospitalizations and morbidity and improve functional status.1
Patients are thoroughly evaluated at each clinic visit, including checks of electrolyte levels and renal function. Laboratory test results are available before the patient leaves so meds can be adjusted if necessary. Evaluating a patient’s readiness for cardiac transplant is an ongoing consideration.
Patient education is seen as an essential function of the facility, and the multidisciplinary program includes information about the disease, meds, nutrition, and lifestyle modification. Rehabilitation personnel encourage exercise and form support groups for patients and families. A pastoral care segment of the program helps with acceptance and emotional support. Patients at the Heart Failure Center with end-stage CHF who no longer respond to conventional therapy are offered alternative treatments, made possible by clinical research funding.
"We can currently treat three patients at a time," says Torpy, "but we’re about to expand to five. We have a waiting list. When we put the program together 21¼2 years ago, we had no idea how many patients would need this kind of therapy. We now see over 200 patients, so have to expand to accommodate them."
The infusion stations at the Heart Failure Center allow administration of IV fluids, diuretics, inotropes, and other meds. They help in another way to cut down on hospital admissions: CHF patients often present to the ED, and the staff there uses the Heart Failure Center’s infusion stations to treat acute decompensation episodes, perform hemodynamic monitoring and elective cardioversions, and administer antiarrhythmic therapy. After a patient improves, he or she can be conveniently transferred to the Heart Failure Center. Hospitalization is considered only when outpatient treatment is not feasible.
The center keeps a database of heart failure patients that is electronically linked to the ED so physicians there have easy access to patient records. The database contains vital statistics, as well as dates and results of past echocardiograms, cardiac catheterizations, bypasses, radionuclide ventriculography, and oxygen consumption.
CHF is medically complex and the No. 1 Medicare DRG. Hospital admissions have increased by 5% over each of the past five years. CHF patients cost more than $10 billion a year, stemming mostly from ED visits and inpatient services because their conventional care amounts to cyclical crisis management repeated ED and physician visits and hospitalizations.
The clinical and economic consequences of CHF are enormous. Hospitals expend significant clinical resources on their pools of CHF patients, and those pools are large and growing. Because of treatment advances, patients are living longer and overutilizing resources.
When the Heart Failure Unit at Michael Reese started up five years ago, they had one patient and one part-time RN; now the unit is one of the largest in the country. A nurse clinician, nurse program coordinator, medical director, and cardiology fellows administer on average more than 20 four-hour infusions daily, four days a week. Five patients can be infused simultaneously.
Unit is not typical for outpatients
"This is not a typical outpatient unit," says Heaney. "It’s more like critical care on an outpatient basis. Every patient receiving medication is on telemetry monitoring, and we take vital signs frequently. Patients are always under the direct supervision of an RN or physician."
"If a patient is having chest pain, indicating CHF with coronary artery disease, we watch very closely," she continues. "If there’s an EKG change that would indicate an ischemic process, we admit."
A patient is excluded from the Heart Failure Unit program in the following cases:
• history of acute myocardial infarction and/or unstable ventricular arrhythmias within three months;
• aortic or mitral valve stenosis;
• hypertrophic cardiomyopathy;
• intracardiac masses or thrombus;
• history of repeated noncompliance;
• history of alcohol or drug abuse.
Pregnancy is a contraindication, and women in childbearing years must practice contraception.
The nursing staff follow patients throughout their care. Because patients are there once or twice a week, home health nurses are rarely needed.
Improvement in quality of life is important in these patients. The Heart Failure Unit has administered the Minnesota Living With Heart Failure questionnaire to patients every month for the past two years. The instrument elicits information on functional capability, symptom level, and psychosocial adjustment. After six months of therapy the improvement in mean scores was 58% in 90 patients.2
Suggested reading
Chapman DB, Torpy J. Development of a heart failure center: A medical center and cardiology practice join forces to improve care and reduce costs. Am J Man Care 1997; 3:431-437.
Marius-Nunez AL, Heaney L, Fernandez RN, et al. Intermittent inotropic therapy in an outpatient setting: A cost-effective therapeutic modality in patients with refractory heart failure. Am Heart J 1996; 132:805-808.
References
1. Kornowski R, Zeeli D, Averbuch M, et al. Intensive home care surveillance prevents hospitalization and improves morbidity rates among elderly patients with severe congestive heart failure. Am Heart J 1995; 129:762-766.
2. Heaney L, Antonio C. Outpatient infusion clinics: A strategy for the successful management of advanced heart failure. Journal of Cardiovascular Management 1997; Jan/Feb:12-16.
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