Key to CHF compliance is monitoring measures
Quick feedback saves $3 million in care
One of the difficulties in managing chronic illness is that provider systems can easily get left behind by rapidly advancing treatment protocols if they are not diligent in staying current with best practices. Nowhere is this more important than in congestive heart failure.
CHF is responsible for almost one million hospitalizations every year and is the most common diagnosis in hospital patients age 65 and older. It accounts for about $20 billion in health care costs each year.
If you’re not using best practices with your CHF patients, not only do your patients suffer, but your bottom line will suffer as well. Such was the case with NYLCare Health Plans of New York. "Congestive heart failure was costing us a fortune," admits John Roglieri, MD, NYLCare medical director.
By all measures, NYLCare was not effectively managing its CHF populations: 47% were readmitted to the hospital within 90 days, 72% of hospital admissions were related to CHF, and only 25% were treated with drugs, specifically the ACE inhibitors recommended by national guidelines.
Program cuts costs, increases compliance
NYLCare opted to bring in a disease management firm to design a program to decrease hospitalizations while cutting costs and increasing compliance. According to Roglieri, the program has saved his company $3.1 million since it was implemented in October 1995 and has paid for itself many times over. (See chart on p. 17 for the type of utilization improvements that made these savings possible.)
The key to the program’s success was identifying several crucial clinical measures to monitor, then educating physicians and patients to bring them into compliance with best care practices. The disease management company, Stuart Disease Management Services in Wilmington, DE, began with national guidelines from the Agency for Healthcare Policy and Research in Washington, DC.
"The AHCPR Left Ventricular Systolic Function Guidelines were the backbone of our guideline, and we supplemented that with other pieces in the literature, such as the American College of Cardiology and the American Heart Association practice parameters," explains Kenneth McDonough, MD, medical director for SDMS. Then this "guideline template" was submitted to NYLCare’s physician leadership for review and customized with its input.
"If national guidelines meet local practice customs and are approved by the audience, they are much more apt to be examined and followed," McDonough says. He emphasizes that the guideline is not a static document. His company provides regular updates as necessary to keep it current.
With the document for delineating best practices complete, SDMS then developed a program for measuring and monitoring in four major areas: clinical outcomes, patient satisfaction, quality of life, and economic outcomes.
Patients surveyed on quality of life
Literature searches did not turn up any widely accepted satisfaction survey for CHF patients, so SDMS developed its own, which it is continuing to improve, says McDonough. For quality of life, SDMS uses the Minnesota Living With Heart Failure Questionnaire.
The clinical measures are designed to show how well the patient is functioning and his or her degree of compliance with treatment regimens. Physicians measure each patient’s ejection fraction (a measure of heart function), and stratify his or her disease state according to the New York Heart Association classifications (Class I through IV), based on symptoms and degree of impairment.
"We also look at weight," continues McDonough. "We look at some scoring of patient symptoms and whether they’ve run out of medication and those kinds of things. And finally, we look at their specific medication usage, if they are staying on medication suggested by their doctor or recommended by the practice guideline."
Constant contact keeps patients on track
To monitor these patients, SDMS uses nurse case managers who call patients weekly or more often if the patient is unstable, and/or arrange for a home visit by a home agency, whose nurses have been contracted and trained by SDMS. Patients also receive monthly educational mailings.
"The patient owns the disease," explains Roglieri. "If you’ve got congestive heart failure, it’s probably going to kill you. We don’t know when. Your doctor’s got 22 patients in the morning and another 30 in the afternoon. It has to be your deal. You’ve got to take your medications, avoid salt, get some exercise, weigh yourself every day. We’re going to call and ask you how you’re doing. That’s patient empowerment."
The telemonitoring is housed in SDMS’ Wilmington offices, but SDMS’ personnel identify themselves as NYLCare agents when talking with patients. Physicians receive feedback on their patients either by mail, a fax, or a phone call. If the information is urgent, then the physician gets both a fax and a phone call.
Reports are generated by each home visit, telephone call, and physician office visit. Aggregate data go to NYLCare corporate offices, where they are integrated with claims data to generate financial outcomes. Jim Skelly, RN, NYLCare director of disease management programs, gets utilization reports quarterly, and weekly or biweekly updates on who’s in the plan or out of it.
Patients are enrolled in the plan based on claims data and their physician’s or SDMS’ recommendation. About 340 patients are currently enrolled in programs in New York, Texas, and North Carolina, says Skelly, but he’d like to see that grow to several thousand. "Certainly, we’ve got the population to support that," he says.
Interestingly enough, when surveying their insureds, many CHF patients "did not see CHF as an important force in their lives," Skelly notes, alluding to the patient education necessary to make a program like this work. The physicians in their provider networks, however, have been very pleased.
"Physicians love it," Roglieri says. "We get the patients off their backs. We tell them when a patient’s getting into trouble. The patients wait for our phone call instead of theirs. What’s not to like? Every physician needs an extra pair of hands and an extra pair of ears, and that’s what we’re giving them."
One of the chief benefits that provider and payer systems realize from a program like this is that the information technology burden for tracking, collecting, analyzing, and compiling the data into reports is shouldered by the disease management firm. This allows companies like NYLCare and its provider systems to enjoy state-of-the-art outcomes tracking and reporting technology, without the capital investment in the systems or the maintenance.
Information technology speeds reports
At SDMS, the nurses type their phone reports directly into SDMS’ database. Many of the home care nurse agencies provide their staff with laptops, which carry SDMS forms so the data can be downloaded electronically directly into SDMS’ information systems. SDMS also takes care of integrating any data that must be manually loaded into the system, such as physician reports or lab data. SDMS ships its reports to NYLCare by e-mail, which facilitates fast and easy dissemination both between the companies and within NYLCare.
McDonough says financial analysis of the pilot program done for NYLCare shows that the payer enjoyed a 4:1 net return on its initial investment. "We don’t know if that will hold up when we take it out to other plans," he admits. "But that return could shrink some and still be a significant return."
{For more information, contact Kenneth McDonough, MD, MS, vice president and medical director for SDMS Disease Management Services, Little Falls Centre One, Suite 100, 2711 Centerville Road, Wilmington, DE 19808. Telephone: (302) 892-4435. John Roglieri, MD, medical director for NYLCare Health Plans of New York, One Liberty Plaza, New York, NY 10006-1404. Telephone: (212) 437-1563.]
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