Education efforts reduce CHF costs
Here’s how three programs get results
Congestive heart failure (CHF) ranks in Medicare’s top three diagnoses for inpatient payment. With a minimum cost of $3,500 per CHF admission, case managers who learn the secrets to helping patients control this expensive chronic disease hold the key to saving health plans big health care dollars.
Experts interviewed by Case Management Advisor say that there are several reasons that so many CHF patients have difficulty managing their disease. (For further discussion about why CHF management often fails, see story on p. 55.) Those reasons include:
• lack of understanding about CHF;
• inadequate educational materials;
• lack of home resources for disease management;
• noncompliance with diet, exercise, and medication plans;
• lack of adequate outpatient monitoring of clinical indicators.
Home monitoring cuts admissions
"CHF is a progressive disease, and patients can deteriorate significantly between office visits," notes Ken L. McDonough, MD, MS, medical director for SDMS, a health care consulting company in Wilmington, DE. "If health plans implement programs to monitor patients in between physician visits and to alert physicians that there are complications before patients are sick enough to be hospitalized, many complications can be successfully treated on an outpatient basis."
In fact, home monitoring between office visits did help reduce hospital admissions for a physician group in Minnesota.
"We reviewed patient charts and found that our patients were receiving good quality care in the hospital with a sufficient resolution of symptoms on discharge. Yet, these patients still fell apart once they got home," notes Wanda Strandberg, RN, managed care coordinator for Northstar Physicians Plan, a network of primary care clinics in Duluth, MN.
"We developed a program that used home health nurses to deliver additional teaching and monitoring in the home setting, where patients were better able to retain the necessary information," she explains.
Tools of the trade
Northstar arms home health nurses with CHF symptom magnets for patients to keep on their refrigerators, medication boxes to help patients organize their prescriptions, and educational materials to reinforce the teaching begun in the hospital, notes Strandberg. "The majority of CHF patients are elderly. Even though they’ve been taught and think they understand CHF management, they need continued reinforcement," she says.
In addition, during weekly home health visits, nurses act as additional "eyes and ears" for the physician, notes Strandberg. "The nurses go in and look in the kitchen cupboards to see what patients are really eating. If they see too many processed foods, they know they have to go back over dietary guidelines," she explains.
The results? In the year prior to the CHF home health program, Northstar had 82 CHF admissions, with a total inpatient cost of $528,000. During the first year of the program, Northstar had only 42 admissions, with a total inpatient cost of $203,529. "Teaching patients used to be easy in the days of long hospital stays. Now that patients leave the hospital so quickly, we must find other ways to give them the skills necessary to manage their disease."
Teaching linked to lasting benefits
Even after home health visits end, Northstar uses the information gathered by home health nurses to continue monitoring patients by telephone. "We might call and discuss dietary guidelines. The nurse may tell us the patient had a cupboard full of processed foods. We’ll check back by telephone occasionally to remind them that’s not good for them."
Strandberg says the extra education also seems to have long-term benefits for CHF management. "We have patients who started the program in 1989 and are still alive and well today. National statistics show that females with CHF live an average of 2.3 years with their disease and males 1.7 years. We have patients out there after eight years," she notes.
Northstar is not alone in believing that CHF patients need continual reinforcement to better manage their disease. Barnes-Jewish Hospital in St. Louis recently launched a nurse-directed CHF clinic under the direction of cardiologist Michael Rich, MD, which focuses on outpatient monitoring and individual counseling for a six-month period. "This program builds on lessons we learned during an earlier project that found CHF-related readmissions could be cut in half with post-discharge monitoring and education, says Carol Wittenberg, RN, BSN, the clinical nurse director for the Barnes-Jewish research project.
"When patients come to the clinic, I conduct a cardiovascular nursing examination. I listen to the heart and lungs and check for edema," explains Wittenberg. "By coming in for clinic visits between scheduled physician visits, we can intervene early before complications escalate and result in an admission," she notes. "If I notice any indications of trouble, I contact the physician."
"I also sit down and talk with each patient individually about medications and try to identify any barriers to compliance. Sometimes, patients experience uncomfortable side effects, or the regime is too complicated or too expensive," says Wittenberg. "Dr. Rich is always available to me in case I need to consult him about the possible need for changes in medication," she adds.
In addition, Wittenberg discusses dietary guidelines and exercise with patients. "In the hospital environment, the teaching is so rushed that learning can’t take place," she says. "Each patient has different needs when it comes to managing their CHF. For some, diet is the difficult area. Others find medications too confusing. You are dealing with a primarily geriatric population, and they do require some repetition," Wittenberg, explains, adding that the first Barnes-Jewish CHF program included three months of follow-up, and some patients still did not seem ready to manage their disease successfully.
Barnes-Jewish provides patients with a 15-page CHF management booklet developed by Rich. "I have pretty strong feelings about written materials. I don’t believe in giving patients too much. It’s just confusing and patients often can’t absorb it all. Sometimes, the print is too small for elderly patients, or the material is too wordy. I like the 15-page booklet. I use it as an outline to help me go over important points," says Wittenberg.
Use the phone
However, health plans do not necessarily have to set up special CHF clinics to yield good outcomes. SDMS provides weekly telephonic monitoring for patients in its CHF disease management program with excellent results, says McDonough. "We looked at total hospital days for high-index patients before and after participating in our CHF program and found a 61.7% decrease in average inpatient days for one managed care client," he notes, adding that high-index patients include patients with one or more hospital intensive care admissions for CHF.
A SDMS nurse first contacts the physicians of high-index CHF patients to gather information about the patient, gain physician support for the program, and set baseline measures for such factors as weight, notes McDonough. After the physician approves a patient’s enrollment in the program, the nurse contacts the patient by telephone to collect more information, including:
• symptoms experienced;
• medical history;
• dietary and medication compliance.
"Nurses also administer a quality-of-life assessment to try to determine how much impact their CHF has on patients," he says. "We want to understand how patients perceive their life and how that improves or deteriorates over time, so that we can better target our program interventions," McDonough explains.
Nurses call patients weekly to see if their symptoms are better or worse, notes McDonough. "Nurses also educate patients about areas of CHF management. The foundation of any disease management program has to be patient education. We view ourselves as physician extenders. The nurses support the physicians by providing additional monitoring and education," he says.
Asking the right questions
To help monitor patient progress by phone, nurses go over a series of questions with patients during each telephone call, McDonough explains. "By repeating the same set of questions each week, nurses can easily chart whether patients are improving or deteriorating. If there are any indications that a patient is worsening, the nurse contacts the patient’s physician so that appropriate action can be taken."
SDMS also provides physicians with practice guidelines for CHF management based on an extensive literature review and established national standards, notes McDonough. "We feel that in this way there’s a carry-over benefit for other patients who are not directly enrolled in the program," he explains.
[Nonprofit hospitals can purchase the 15-page booklet, Congestive Heart Failure, A Patient’s Guide, for $2 a copy from Barnes-Jewish Hospital. The booklets are available to for-profit hospitals by a licensing agreement. For more information, contact: Carol Wittenberg, Barnes-Jewish Hospital, 216 S Kingshighway, St. Louis, MO, 63110. Fax: (314) 454-5265. For more information about SDMS disease management programs, contact: Jack G. Duncan, president, SDMS, Little Falls Centre One, Suite 100, 2711 Centerville Road, Wilmington, DE 19808. Telephone: (302) 892-4404. Fax: (302) 892-4444.]
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