Setting up a telemanagement system
Keeping connected
As the director of the Heart Failure and Transplantation Management Center at the University of Michigan in Ann Arbor, Robert Cody, MD, oversees the treatment of about 800 heart failure patients and 200 transplant recipients. He says his goal is to help his patients avoid as many hospitalizations and emergency room trips as possible. Telemanagement is a big part of the program.
"We don’t wait for the patients to call us," he says. "We’ve turned the telephone into a preventive weapon. . . . It’s a pre-emptive strike of a maintenance approach."
Cody says his group tries to provide a safety net against heart failure. The center uses four full-time nurses and one on a half-time basis to make the calls, talk to patients, and track their condition. Patients stay in contact with Cody’s telephone team when they go on vacation, and some live as far as 12-hours away by car.
"We’re kind of their lifeline," adds Karen Stemmer, MSN, RN, the facility’s clinical care coordinator.
Patients get involved with the center in different ways. Of course, there is the traditional path of direct referral from a physician. Other patients are brought on board as part of their individual health insurance programs.
The Michigan center will completely take over some disease management cases on the referring physician’s request. For other patients, the group plays more of a supportive role, while the personal physician directs the treatment. Cody notes similar facilities are popping up throughout the country. But any practice could develop its own telemanagement system, he says. "Any physician’s office treating heart failure could obtain training for office staff, to do what we are doing on a smaller scale."
Whether doctors look to larger centers as models or develop their own plans, the system should try to achieve specific goals. Cody says his center tries to do the following:
o Get patients to participate in their own care.
Educate them about their condition, medications, and diet needs. Make sure they recognize symptoms of trouble, such as daily weight gain or shortness of breath becoming more severe.
o Assist in identifying irregular schedules of lab tests and making more suitable ones.
This is when you make sure blood and electrolytes are being checked regularly.
o Monitor drugs and know how to handle the responses you get.
Callers review medication schedules and try to get a sense of patient compliance. (See related story on drug compliance issues, p. 8.)
"You establish a trust and rapport with them on the phone," Stemmer says. "Usually you can pick up what they are really saying." For example, if patients tell their caller they have been having financial problems, it may be a hint that they can’t afford their medication, so they haven’t been taking it. "Then we try to connect them with a social worker who can help with indigent services."
One payoff, Cody says, is that the nurses develop their own sense of when a patient needs attention beyond the calling schedule. Many times, a nurse can hear something that doesn’t seem quite right. "Nurses develop an instinct to call patients earlier," he says, "they begin to hear things in the patients voice that could be the start of problems."
The rapport also means that patients can feel more comfortable calling their nurses as well. If symptoms seem to be changing, the patient can get instructions to go to the right lab for tests, for example, or can inform physicians that treatment may need to be changed, Cody says.
Before callers can bond with their patients, Stemmer says that there must be some strong ties established among staff in the individual practice. She notes that there must be a special relationship between the callers and the doctors who support them. For example, Cody consulted with Stemmer to determine the proper ratio of patients for each caller.
Stemmer says to be effective, doctors should adopt these attitudes toward telemangement staff:
¤ mentoring;
¤ respectful;
¤ collegial;
¤ trusting.
As you work on internal rapport, some other components to consider in structuring the telemanagement system are:
o Frequency of calls.
Obviously, frequency will depend on the severity of the patient’s condition. Stemmer says some patients who are stable in NY Heart Association Class I or Class II CHF can be called every few months. The bulk of her patient load has Class III and IV disease and need constant monitoring. "You may call twice a day," she says, to make sure [patients] took their diuretic and then later on to make sure it is working.
o Anatomy of calls.
Again, specifics will vary with the patient. But there are some general categories to think about. Richard Pozen, MD, national medical director of Vivra Heart Services in Fort Lauderdale, FL, and its HeartAssist CHF disease management program, says there are some standard questions to ask such as:
— How much do you weigh today?
— Do you have any of these symptoms:
(1) swollen feet;
(2) shortness of breath;
(3) chest discomfort.
The caller should be ready to consult the doctor if a red flag goes up, such as a weight gain of two or three pounds (or more) in a day, he says. "You tell the doctor that Mrs. Jones weighs four pounds more today and maybe we should see her now."
Pozen says that the caller should also assess the quality of the patient’s life on a regular basis. Questionnaires are available from many sources, such as one he uses as a licensed agreement with the University of Minnesota.
The telephone conversation also is a good time to educate the caller on one aspect of treatment, which can be different with each call. "You don’t want to give them an encyclopedia," he says, "just something different each time."
o Information integration.
Don’t let important facts about a patient become marooned on a phone-side notepad. Stemmer says the notes taken during the calls become part of the patients’ records. They go to the clinic with patients and help to record the status of their condition.
o CHF team endorsement.
The physician should make patients aware that others are involved in ensuring good patient care. "If doctors use physician extenders to make calls, introduce that idea to the patient during the appointment," says Christine K. O’Neil, PharmD, assistant professor of clinical pharmacy at Duquesne University in Pittsburgh. "Make the patient feel comfortable that this office person or someone besides the doctor will call and that it is important to talk freely."
Remember that the telemanagement system is designed to promote patient understanding and patient self-management, Pozen says, noting his group has been able to reduce hospital readmissions by 40%. "Whether you do it in your office or contract out to a management source, the key is all the same: to help educate [patients] and give them more attention."
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